Brain and Spine 2 (2022) 101100 Contents lists available at ScienceDirect Brain and Spine journal homepage: www.journals.elsevier.com/brain-and-spine Gender differences in work-life balance of European neurosurgeons Xanthoula Lambrianou a, Christos Tzerefos a, Insa K. Janssen b, Stiliana Mihaylova c, Aysegul Esen Aydin d, Selma Al-Ahmad e, Marike LD. Broekman f, Nurperi Gazioglu g, Silvia Hernandez Duran h, Daniela Luminita Ivan i, Maria Karampouga j, Hulda B. Magnadottir k, Ermira Pajaj l, Ana Rodríguez-Hernandez m, Gail Rosseau n, Niina Salokorpi o, Eleni Tsianaka p, Pia Vayssiere b, Mary Murphy q, Anastasia Tasiou a, * a Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece b Department of Neurosurgery, H^ opitaux Universitaires de Geneve, Geneva, Switzerland c Clinic of Neurosurgery, Sv. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria d Department of Neurosurgery, Arnavutkoy State Hospital, Istanbul, Turkey e Neurosurgery Department, Sheffield Teaching Hospitals, Sheffield, UK f Department of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden, the Netherlands g Istinye University, Medical Faculty, Department of Neurosurgery, Istanbul, Turkey h Klinik für Neurochirurgie, Universit€ atsmedizin G€ottingen, G€ottingen, Germany i Department of Neurosurgery, Bucharest Emergency University Hospital, Carol Davila University of Medicine, Bucharest, Romania j Neurosurgery Department, Nicosia General Hospital, Nicosia, Cyprus k Upper Valley Neurology Neurosurgery, Lebanon, NH, USA l Department of Neurosurgery, Spitali Rajonal Memorial Fier, Fier, Albania m Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Universidad Autonoma, Barcelona, Spain n Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA o Department of Neurosurgery, Oulu University Hospital, Oulu, Finland and Research Unit of Clinical Neuroscience, Medical Research Center, Oulu University, Oulu, Finland p Neurosurgery Department, International Hospital, Salmiya, Kuwait q Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK A R T I C L E I N F O A B S T R A C T Keywords: Introduction: Neurosurgery is one of the most demanding medical specialties. For neurosurgeons, balancing Career professional activity with personal life can be challenging. Children Research question: To evaluate gender differences in contribution of neurosurgeons in the household and child- Gender differences rearing, as well as their impact on personal life and career. Home responsibilities Neurosurgeon Material and methods: An anonymous, electronic, 59-item web-based survey was administered to National Work-life balance Neurosurgical Societies of Europe, and European Member Societies of the European Association of Neurosurgical Societies (June–October 2021). Results: A total of 205 European neurosurgeons (87 females and 118 males, mean age 40.7) are included in our survey. In neurosurgery, females are significantly more likely to be alone (37.9%), while males are significantly more likely to have children (66.9%). In terms of household efforts, females spend more time than males on the same tasks. Most participants (71.2%) view gender issues as a disadvantage in career pursuing. Women feel less accepted (54.3%) and having fewer opportunities (58.6%), while men believe that pregnancy/child-rearing (65.8%) and having many roles (51.3%) are the main obstacles. Both genders (77.6%) favor more convenient working conditions for young parents. Discussion and Conclusion. In our study we found that, women neurosurgeons take more responsibilities at home, especially in the child-rearing years. Female neurosurgeons are more likely to live alone or stay childless more often compared to their male colleagues. Supportive facilities, flexible programs, universal life policies and presumably curbing of the social stereotypes are of importance to overcome gender inequities that women are still facing in neurosurgery. * Corresponding author. Department of Neurosurgery, Building A, 3rd Floor, University Hospital of Larissa, Biopolis, Larissa, 41110, Greece. E-mail address: ttasiou@yahoo.com (A. Tasiou). https://doi.org/10.1016/j.bas.2022.101100 Received 25 May 2022; Received in revised form 16 August 2022; Accepted 25 August 2022 Available online 5 September 2022 2772-5294/© 2022 The Authors. Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical Societies. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). X. Lambrianou et al. Brain and Spine 2 (2022) 101100 1. Introduction standard deviation, while categorical survey answers were summarized using counts and proportions. Survey answers were analyzed based on The role of women in society has dramatically changed over the last the participants' gender. The results of specific questions between women two centuries. Women have earned voting rights, equal rights and equal and men respondents were compared using Pearson's chi-square or opportunities in many countries. The social stereotype that women Fisher's exact test. For statistical analysis purposes the participants were should stay at home to do the housework and to raise their children, further separated into registrars/residents and consultants/attending while men should do paid work outside home has gradually been neurosurgeons according to their professional status. A univariate anal- demolished around the world. Nowadays, it seems that the roles are ysis, using logistic and ordinal regression analysis, was performed to converging. However, balancing family and work responsibilities is still investigate the role of age, gender, and professional status, as de- challenging, irrespective of gender. terminants in certain questions, while a multivariate analysis was con- In medical schools, women outnumber men in many countries around ducted, when necessary. Odds ratios (ORs) and 95% confidence intervals the world (Abosch and Rutka, 2018). However, neurosurgery is still (95% CIs) obtained from the logistic regression analysis were presented. considered a male-dominated field, especially in leadership positions. For all the performed tests, the threshold for statistical significance was Undoubtedly, the percentage of women entering into neurosurgery has set at p < 0.05. been increasing over time. In 2016, the percentage of women recruited into neurosurgery across Europe was 29%, while at the same time the 1.2. Results number of board-certified female neurosurgeons was only 9% (Stekla- cova et al., 2017). Likewise, the percentage of female neurosurgery res- 1.2.1. Overview idents in the US increased from 10.7% in the 1990's to 15.5% in 2012, A total of 205 eligible responses were received. Questions were while the number of women finishing their residency increased from divided into three categories, as described in the Methods section, and 76% in the 1990's to 83% in the 2000s (Renfrow et al., 2016). Although responses were slightly modified or excluded during statistical analysis the neurosurgical workforce remains male-dominated, it is clear that for homogeneous analysis purposes. there is now a positive trend for women to be attracted towards a career in neurosurgery. 1.2.2. Demographics Neurosurgery is one of the most demanding specialties. Irrespective Participants of the survey represented 19 European countries, of gender, neurosurgeons have to combine the exhausting professional including Turkey. Our study population was assigned using the gender program during training or practice, with their personal lives, family, and binary: women and men. There were 87 females and 118 males (42.4% child-rearing responsibilities. In our communication, we would like to and 57.6%, respectively). The participants’ age ranged between 26 and outline gender differences, if any, in neurosurgery and with this oppor- 65 years, while the mean age was 40.7 years (SD: 9.4, Table 1). tunity to trigger a discussion about undersurface and sensitive gender The majority of respondents answered that they work in a public equality issues that could shed light on existing social stereotypes across hospital (86.3%), being full-time employees (96.1%). Most of them were Europe and around the globe. consultants/attending neurosurgeons (65.4%), while 71 (34.6%) were registrars/residents. The collected data regarding the neurosurgical 1.1. Methods experience of our participants was summarized in Table 2. Fifty participants (24.4%) stated that they live alone. Females were 1.1.1. Study methodology significantly more likely to be alone (37.9%) than males (14.4%, p < An anonymous, digital, 59-item web-based survey was distributed 0.05). Univariate analysis showed that the probability of living alone is using the Google Forms platform, from June 24, 2021, to October 31, negatively associated with both determinants, age [p < 0.001, OR ¼ 2021. The survey was administered to the National Neurosurgical Soci- 0.91, 95% CI (0.88, 0.96)] and higher professional status [consultants/ eties of Europe, and the European Member Societies of the European attending neurosurgeons, p < 0.001, OR ¼ 0.30, 95% CI (0.15, 0.58)]. Association of Neurosurgical Societies (EANS). The purpose of the survey was to identify and outline any gender differences in the contribution of a Table 1 neurosurgeon, in the household and childcare and its impact on personal Neurosurgeons’ demographic characteristics. life and career pursuit. Variables Mean (Standard Deviation) The web link of the survey was circulated via emails to the target group. The first 20 questionnaires were used to check the feasibility of Age 40.7 (9.4) the survey. After pilot testing, the final version was formed (supple- Number Percentage (%) Gender mentary material). Three reminders were launched after the initial Male 118 57.6 release for maximizing the participation in our survey. Female 87 42.4 An introductory letter describing the purpose of the survey was sent Country and recipients who voluntarily decided to participate had to click on the Albania 11 5.4 Bulgaria 8 3.9 web link access the survey. Residents, consultants/attending, and retired Croatia 1 0.5 neurosurgeons were eligible to fill out the questionnaire. Responses from Cyprus 10 4.9 EANS Individual Members were also included in our survey (Table 1). France 2 1.0 Incomplete responses were excluded from our analysis. Selected ques- Germany 5 2.4 tions allowed participants to reply through a multiple-choice responding Greece 55 26.8 Iceland 2 1.0 system and add comments in text boxes, if necessary. Questions were Italy 21 10.2 categorized in to three groups: demographics, personal life/daily routine Montenegro 1 0.5 and experience in neurosurgery. The respondents could optionally pro- Netherlands 1 0.5 vide their email addresses. Portugal 1 0.5 Romania 4 2.0 Serbia 3 1.5 1.1.2. Statistical analysis Spain 9 4.4 The statistical analysis was independently conducted by two authors, Sweden 2 1.0 a female and a male neurosurgeon (AEA and CT, respectively). The Switzerland 17 8.3 analysis was performed using the IBM SPSS v.20 package (IBM Corp, Turkey 13 6.3 United Kingdom 39 19.0 2011). Age was presented as a continuous variable using mean value and 2 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Table 2 Table 2 (continued ) Our data in regards to work-life status of neurosurgeons and their partners in life. Questions Gender Total p-value Questions Gender Total p-value Female Male Female Male Who is gaining more 0.000a Serve in: 0.453a money?b Public Section 78 99 177 Me 20 74 94 (89.7%) (83.9%) (86.3%) (37.0%) (73.3%) (60.7%) Private Section 9 17 26 My spouse/partner 22 5 (5.0%) 27 (10.3%) (14.4%) (12.7%) (40.7%) (17.4%) I prefer not to answer 0 (0.0%) 2 (1.7%) 2 (1.0%) Equally 11 15 26 Professional status: 0.072 (20.4%) (14.9%) (16.8%) Resident 36 35 71 I prefer not to answer 1 (1.9%) 7 (6.9%) 8 (5.2%) (41.4%) (29.7%) (34.6%) a Fisher exact test was applied. Attending neurosurgeon/ 43 57 100 b Consultant (49.4%) (48.3%) (48.8%) The total number of participants living with a partner/spouse is 155. Head of the Department/ 3 (3.5%) 10 13 Chair (8.5%) (6.3%) However, only the association with gender remained significant after the Professor 5 (5.8%) 16 21 multivariate analysis. More than half of respondents who do not live (13.6%) (10.2%) Retired neurosurgeon 0 (0.0%) 0 (0.0%) 0 (0.0%) alone (51.5%) reported that the profession of their partner/spouse is Current experience in 0.013a health care associated, including neurosurgeons, medical doctors of neurosurgery? other specialty, or other kind of health professionals (7.7%, 29.0% and Resident 36 35 71 14.8%, respectively). (41.4%) (29.7%) (34.6%) 0–10 years post-residency 33 32 65 Moreover, our survey revealed that most neurosurgeons (109/205, (37.9%) (27.1%) (31.7%) 53.2%) work on average 40–60 h per week (h/w), while their partners/ 11–20 years post- 11 29 40 spouses (78/155) work on average less than 40 h/w (50.3%, Table 2). residency (12.6%) (24.6%) (19.5%) Many of our participants (60.7%) stated that they earn more money than 21–30 years post- 7 (8.1%) 21 28 their partners/spouses (Table 2). After further gender-based analysis, we residency (17.8%) (13.7%) More than 30 years post- 0 (0.0%) 1 (0.9%) 1 (0.5%) found that male neurosurgeons are the bread winners (73.3%) while residency female neurosurgeons earn less money than their partners/spouses Employment: 0.853a (37.1%). This difference was statistically significant (p < 0.05). Full time 83 114 197 (95.4%) (96.6%) (96.1%) Part time 3 (3.5%) 3 (2.5%) 6 (2.9%) 1.2.3. Personal life and daily routine I prefer not to answer 1 (1.2%) 1 (0.9%) 2 (1.0%) One hundred eighteen participants (57.6%) reported that they have Household status 0.000139 children (Table 3). It is noteworthy that men in neurosurgery are I live alone 33 17 50 significantly more likely to have children than women (66.9% vs. 44.8%, (37.9%) (14.4%) (24.4%) p < 0.05). Among neurosurgeons with no children, 36.8% answered that I live with a spouse/partner 54 101 155 (62.1%) (85.6%) (75.6%) childbirth is not their main priority, while 33.3% supported that it is not Your partner's/spouse's 0.001a in their family plan. Long working hours (19.5%), dedication to career profession:b (13.8%), and lack of support (9.2%) were also reported as strong con- Neurosurgeon 6 6 (5.9%) 12 cerns for not having children. Importantly, more than half of respondents (11.1%) (7.7%) Medical doctor 15 30 45 (53.2%) reported that they have only once a week spare time for lifestyle (27.8%) (29.7%) (29.0%) (Table 3). However, 89 (43.5%) of our population expressed their Scientist 2 (3.7%) 11 13 satisfaction in terms of lifestyle-work balance, while 75 (36.6%) (10.9%) (8.4%) emphasized that they feel frustrated (Table 3). Gender did not affect Self-employed 8 4 (4.0%) 12 these responses (p > 0.05). Nonetheless, univariate ordinal regression (14.8%) (7.7%) Health worker 3 (5.6%) 20 23 analysis demonstrated that male gender [p ¼ 0.05, OR ¼ 1.64, 95% CI (19.8%) (14.8%) (1.01, 2.70)], older age [p ¼ 0.007, OR ¼ 1.03, 95% CI (1.01, 1.06)] and Housewife/househusband 1 (1.9%) 12 13 advanced professional status [p ¼ 0.003, OR ¼ 2.21, 95% CI (1.31, 3.73)] (11.9%) (8.4%) increases the possibility of reporting satisfied with the current amount of Other 19 18 37 (35.2%) (17.8%) (23.9%) spare time. How many hours per week 0.896a The majority of neurosurgeons who do not live alone described their on average do you work? partners/spouses as generally supportive and helpful in personal Less than 40 h 3 (3.5%) 6 (5.1%) 9 (4.4%) decision-making and career pursuit (Table 4). Decision-making is usually 40–60 h 47 62 109 a matter for both mates in a couple (56.1%, Table 4). We found that males (54.0%) (52.5%) (53.2%) 61–80 h 27 39 66 feel more supported by their partners/spouses in terms of personal life (31.0%) (33.1%) (32.2%) issues compared to their female counterparts (p < 0.05, Table 4). Addi- More than 80 h 10 11 21 tionally, most of the participants reported that they have significant help (11.5%) (9.3%) (10.2%) with housework and home duties (Table 4). In terms of household efforts, How many hours per week 0.070a on average does your male neurosurgeons' partners/spouses spend more time than female partner/spouse work? b neurosurgeons’ partners/spouses on the same tasks (p < 0.05). However, Less than 40 h 20 58 78 regression analysis model showed that age and professional status do not (37.1%) (57.4%) (50.3%) play any co-founding role (p > 0.05). 40–60 h 25 35 60 Table 5 depicts the daily routine of a neurosurgeon. According to (46.3%) (34.7%) (38.7%) 61–80 h 7 6 (5.9%) 13 gender association, females spend much more time cleaning (44.8%) and (13.0%) (8.4%) cooking (59.8%) in comparison to males (11.0% and 17.0%, respectively, More than 80 h 2 (4.0%) 2 (2.0%) 4 (2.6%) Table 5). Additionally, 38.0% of females spend more than 6 h on housekeeping compared to only 25.3% of males. Male neurosurgeons 3 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Table 3 Table 4 General information in regards to neurosurgeons’ personal life. Our data regarding neurosurgeons’ help and support by their partners in life. Questions Gender Total p- Questions Gender Total p-value value Female Male Female Male Do you have children? 0.002 Is your partner/spouse 0.391b Yes 39 79 118 supportive in general?a (44.8%) (66.9%) (57.6%) Always 25 53 78 No 48 39 87 (46.3%) (52.5%) (50.3%) (55.2%) (33.1%) (42.4%) Often 19 38 57 How many children do you 0.065b (35.2%) (37.6%) (36.8%) have?a Sometimes 9 8 (7.9%) 17 1 18 18 36 (16.7%) (11.0%) (46.2%) (22.8%) (30.5%) Rarely 1 (1.9%) 2 (2.0%) 3 (1.9%) 2 14 45 59 Never 0 (0.0%) 0 (0.0%) 0 (0.0%) (35.9%) (56.9%) (50.0%) Does your partner/spouse 0.005b 3 5 12 17 help you in your personal (12.8%) (15.2%) (14.4%) life (planning, decisions, 4þ 2 (5.1%) 4 (5.1%) 6 (5.1%) etc)?a Please provide the reason for not Always 21 32 53 having children:c (38.9%) (31.7%) (34.2%) Lack of support 6 2 (5.1%) 8 (9.2%) 0.288b Often 18 55 73 (12.5%) (33.3%) (54.5%) (47.1%) Long working hours 11 6 17 0.426 Sometimes 11 5 (5.0%) 16 (22.9%) (15.4%) (19.5%) (20.4%) (10.3%) Dedicated into my career 7 5 12 1.000 Rarely 2 (3.7%) 8 (7.9%) 10 (14.6%) (12.8%) (13.8%) (6.5%) Not my current priority 17 15 32 0.825 Never 2 (3.7%) 1 (1.0%) 3 (1.9%) (35.4%) (38.5%) (36.8%) Does your partner/spouse 0.316b Not in family plan yet 16 13 29 1.000 help you with your (33.3%) (33.3%) (33.3%) career?a I prefer not to answer 2 (4.2%) 8 10 0.038b Always 16 33 49 (20.5%) (11.5%) (29.6%) (32.7%) (31.6%) b Other 8 7 15 1.000 Often 14 37 51 (16.7%) (18.0%) (17.2%) (25.9%) (36.6%) (32.9%) How often do you have spare 0.380b Sometimes 17 17 34 time to satisfy your lifestyle (31.5%) (16.8%) (21.9%) considerations? Rarely 4 (7.4%) 8 (7.9%) 12 Once a week 45 64 109 (7.7%) (51.7%) (54.2%) (53.2%) Never 3 (5.6%) 6 (5.9%) 9 (5.8%) 2-3 times per week 30 44 74 Does your partner/spouse 0.000040b (34.5%) (37.3%) (36.1%) help you with Most days 11 7 (5.9%) 18 housework?a (12.6%) (8.8%) Always 16 66 82 Every day 1 (1.2%) 3 (2.5%) 4 (2.0%) (29.6%) (65.5%) (52.9%) Are you satisfied with your 0.271b Often 18 21 39 professional/personal life (33.3%) (20.8%) (25.2%) balance? Sometimes 16 7 (6.9%) 23 Very satisfied 8 (9.2%) 20 28 (29.6%) (14.8%) (17.0%) (13.7%) Rarely 2 (3.7%) 5 (5.0%) 7 (4.5%) Somewhat satisfied 24 37 61 Never 2 (3.7%) 2 (2.0%) 4 (2.6%) (27.6%) (31.4%) (29.8%) Does your partner/spouse 0.025b Neither satisfied nor dissatisfied 19 22 41 help you with home (21.8%) (18.6%) (20.0%) supplies?a Somewhat dissatisfied 23 30 53 Always 20 49 69 (26.4%) (25.4%) (25.9%) (37.0%) (48.5%) (44.5%) Very dissatisfied 13 9 (7.6%) 22 Often 16 37 53 (14.9%) (10.7%) (29.6%) (36.6%) (34.2%) a Sometimes 14 8 (7.9%) 22 The total number of participants having children is 118. (25.9%) (14.2%) b Fisher exact test was applied. Rarely 4 (7.4%) 5 (5.0%) 9 (5.8%) c The total number of participants with no children is 87. Never 0 (0.0%) 2 (2.0%) 2 (1.3%) Who is the main decision 0.628b maker? stated that their partners/spouses are burdened more with household Me, most of the times 31 42 73 tasks (Table 5, Fig. 1). Interestingly, advanced age predisposes to more (35.6%) (35.6%) (35.6%) housekeeping hours [p < 0.001, OR ¼ 1.06, 95% CI (1.03, 1.10)]. My spouse/partner, most of 4 (4.6%) 10 14 Most neurosurgeons reported that their partners/spouses are essen- the times (8.5%) (6.8%) Equally 50 65 115 tially involved in child-rearing. However, we found a significant gender (57.5%) (55.1%) (56.1%) difference (p < 0.05, Table 6). Daily preparation of children for school, I prefer not to answer 2 (2.3%) 1 (0.9%) 3 (1.5%) transportation to school and caring at night, if necessary, is mostly a mother's responsibility (Table 6). Similarly, gender played a significant The total number of participants living with a partner/spouse is 155. b Fisher exact test was applied. role in child-rearing tasks, such as homework/play and also in the case of an emergency at work or child sickness (Table 6). Seven neurosurgeons (5.9%) identified themselves as single parents. Interestingly, all of them were mothers (18.0% of female population). Most participants agreed that pursuit of clinical or academic career 4 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Table 5 Table 5 (continued ) Neurosurgeons’ contribution at home. Questions Gender Total p-value Questions Gender Total p-value Female Male Female Male No 40 36 76 Who is cleaning? 0.000000a (46.0%) (30.5%) (37.1%) Me, most of the times 39 13 52 Who is looking after elderly 0.021a (44.8%) (11.0%) (25.4%) relatives? My spouse/partner, most of 7 (8.1%) 50 57 Me, most of the times 17 12 29 the times (42.4%) (27.8%) (36.2%) (14.6%) (22.5%) Equally 11 17 28 My spouse/partner, most of 2 (4.3%) 13 15 (12.6%) (14.4%) (13.7%) the times (15.9%) (11.6%) A hired-assistant 28 32 60 Equally 14 26 40 (32.2%) (27.1%) (29.3%) (29.8%) (31.7%) (31.0%) Someone else 2 (2.3%) 6 (5.1%) 8 (3.9%) Other family member 10 26 36 Who is cooking? 0.000000 (21.3%) (31.7%) (27.9%) Me, most of the times 52 20 72 In-home care provider 3 (6.4%) 5 (6.1%) 8 (6.2%) (59.8%) (17.0%) (35.1%) Nursing home 1 (2.1%) 0 (0.0%) 1 (0.8%) My spouse/partner, most of 15 70 85 Do you have pets? 0.435 the times (17.2%) (59.3%) (41.5%) Yes 30 47 77 Equally 7 (8.1%) 14 21 (34.5%) (39.8%) (37.6%) (11.9%) (10.2%) No 57 71 128 A hired-assistant 7 (8.1%) 5 (4.2%) 12 (65.5%) (60.2%) (62.4%) (5.9%) Who is looking after pet(s)? 0.018a Someone else 6 (6.9%) 9 (7.6%) 15 Me, most of the times 15 8 23 (7.3%) (50.0%) (17.0%) (29.9%) Who goes to the super- 0.085a My spouse/partner, most of 5 15 20 market? the times (16.7%) (31.9%) (26.0%) Me, most of the times 46 45 91 Equally 8 21 29 (52.9%) (38.1%) (44.4%) (26.7%) (44.7%) (37.7%) My spouse/partner, most of 18 39 57 Someone else 2 (6.7%) 3 (6.4%) 5 (6.5%) the times (20.7%) (33.1%) (27.8%) a Fisher exact test was applied. Equally 18 31 49 b (20.7%) (26.3%) (23.9%) The total number of participants living with a partner/spouse is 155. A hired-assistant 1 (1.2%) 1 (0.9%) 2 (1.0%) Someone else 4 (4.6%) 2 (1.7%) 6 (2.9%) How many hours per week 0.032a do you spend for housework? 0–5 h 54 88 142 (62.1%) (74.6%) (69.3%) 6–10 h 22 24 46 (25.3%) (20.3%) (22.4%) 11–15 h 10 3 (2.5%) 13 (11.5%) (6.3%) More than 15 h 1 (1.2%) 3 (2.5%) 4 (2.0%) How many hours per week 0.000000a does your spouse/partner spend for housework?b 0–5 h 37 14 51 (68.5%) (13.9%) (32.9%) 6–10 h 16 43 59 (29.6%) (42.6%) (38.1%) Fig. 1. Bar chart depicting the time (hours/week) spent for housework by 11–15 h 1 (1.9%) 20 21 neurosurgeons' partners/spouses. The chart depicts that male neurosurgeons (19.8%) (13.6%) have more help at home by their partners compared to their female colleagues More than 15 h 0 (0.0%) 24 24 based on the hours spent. Although 68.5% of female neurosurgeons' partners (23.8%) (15.5%) spend less than 5 h for housework, only 13.9% of male neurosurgeons' partners Do you have a hired- 0.258 spend the same time. This difference is statistically significant (p < 0.05). assistant? Yes 38 62 100 (43.7%) (52.5%) (48.8%) are negatively affected by childbirth (45.5% and 45.8% respectively, No 49 56 105 Table 6). Notably, this belief is strongly supported by females; 70.1% and (56.3%) (47.5%) (51.2%) 60.9% of females believe that childbirth has a negative impact on clinical How many hours per week 0.008a does the hired-assistant and academic career, respectively (p < 0.05, Table 6). Furthermore, the spend for housework? age of the participants negatively affects the result of these questions, 0–5 h 11 30 41 while this statement is mainly supported by residents. Most women in (29.0%) (48.4%) (41.0%) neurosurgery (65.5%) strongly believe that maternity/paternity is an 6–10 h 11 13 24 obstacle to career pursuit (p < 0.05, Table 6). Both genders (77.6%) favor (29.0%) (21.0%) (24.0%) 11–15 h 0 (0.0%) 7 7 (7.0%) more convenient working conditions for young parents (Table 6). (11.3%) More than 15 h 16 12 28 1.2.4. Experience in neurosurgery (42.1%) (19.4%) (28.0%) Participants were asked if they would mind having a neurosurgeon- Do you have elderely 0.023 relatives? partner. Most of them (69.8%) stated that this would not be a problem. Yes 47 82 129 Perceived lack of time, excessive stress and mental and physical fatigue (54.0%) (69.5%) (62.9%) were the main reasons for those who minded living with a neurosurgeon. When asked whether they would choose neurosurgery as a specialty if 5 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Table 6 Table 6 (continued ) Responsibilities after childbirth. Questions Gender Total p-value Questions Gender Total p-value Female Male Female Male 7 12 19 Does your partner/spouse 0.000b (18.0%) (15.2%) (16.1%) help you with child- Day care 2 (5.1%) 0 (0.0%) 2 (1.7%) rearing?a Who is taking care of child 0.000b Always 16 59 75 sickness in your (41.0%) (74.7%) (63.6%) household?a Often 9 15 24 Me, most of the times 16 1 (1.3%) 17 (23.1%) (19.0%) (20.3%) (41.0%) (14.4%) Sometimes 7 3 (3.8%) 10 My spouse/partner, most of 5 45 50 (18.0%) (8.5%) the times (12.8%) (57.0%) (42.4%) Rarely 4 1 (1.3%) 5 (4.2%) Equally 13 29 42 (10.3%) (33.3%) (36.7%) (35.6%) Never 3 (7.7%) 1 (1.3%) 4 (3.4%) Someone else (babysitter, in- 2 (5.1%) 2 (2.5%) 4 (3.4%) Who is preparing children 0.000b home childcare provider) for school every day?a Other family member 3 (7.7%) 2 (2.5%) 5 (4.3%) Me, most of the times 15 6 (7.6%) 21 Have you ever used a 0.560 (38.5%) (17.8%) parental leave of My spouse/partner, most of 5 52 57 absence?a the times (12.8%) (65.8%) (48.3%) Yes 19 34 53 Equally 5 18 23 (48.7%) (43.0%) (44.9%) (12.8%) (22.8%) (19.5%) No 20 45 65 Someone else (babysitter, in- 13 2 (2.5%) 15 (51.3%) (57.0%) (55.1%) home childcare provider) (33.3%) (12.7%) How long did you leave from 0.000b Other family member 1 (2.6%) 1 (1.3%) 2 (1.7%) clinical duties? Who is transporting children 0.003b Less than 1 month 1 (5.3%) 27 28 to school?a (79.4%) (52.8%) Me, most of the times 7 20 27 1–3 months 7 5 12 (18.0%) (25.3%) (22.9%) (36.8%) (14.7%) (22.6%) My spouse/partner, most of 9 37 46 4–6 months 3 2 (5.9%) 5 (9.4%) the times (23.1%) (46.8%) (39.0%) (15.8%) Equally 9 14 23 7–12 months 4 0 (0.0%) 4 (7.6%) (23.1%) (17.7%) (19.5%) (21.1%) Someone else (babysitter, in- 13 6 (7.6%) 19 More than 12 months 4 0 (0.0%) 4 (7.6%) home childcare provider) (33.3%) (16.1%) (21.1%) Other family member 1 (2.6%) 2 (2.5%) 3 (2.5%) Has your spouse/partner 0.000b Who is getting up in the 0.000b ever used a parental leave nights to look after babies/ of absence?a children?a Yes 13 58 71 Me, most of the times 28 6 (7.6%) 34 (33.3%) (73.4%) (60.2%) (71.8%) (28.8%) No 26 21 47 My spouse/partner, most of 3 (7.7%) 45 48 (66.7%) (26.6%) (39.8%) the times (57.0%) (40.7%) How long did your spouse/ 0.026b Equally 7 27 34 partner leave from clinical (18.0%) (34.2%) (28.8%) duties? Other family member 1 (2.6%) 1 (1.3%) 2 (1.7%) Less than 1 month 6 9 15 Who is helping children with 0.000b (46.2%) (15.5%) (21.1%) their homework?a 1–3 months 4 15 19 Me, most of the times 21 6 (7.6%) 27 (30.8%) (25.9%) (26.8%) (53.9%) (22.9%) 4–6 months 2 5 (8.6%) 7 (9.9%) My spouse/partner, most of 1 (2.6%) 38 39 (15.4%) the times (48.1%) (33.1%) 7–12 months 0 (0.0%) 15 15 Equally 13 32 45 (25.9%) (21.1%) (33.3%) (40.5%) (38.1%) More than 12 months 1 (7.7%) 14 15 Someone else (babysitter, in- 2 (5.1%) 2 (2.5%) 4 (3.4%) (24.1%) (21.1%) home childcare provider) Are you a single parent?a 0.000084b Other family member 2 (5.1%) 1 (1.3%) 3 (2.5%) Yes 7 0 (0.0%) 7 (5.9%) Who takes children to the 0.000b (18.0%) playground or to their No 31 79 110 friends for having fun?a (79.5%) (100%) (93.2%) Me, most of the times 18 7 (8.9%) 25 I prefer not to answer 1 (2.6%) 0 (0.0%) 1 (0.9%) (46.2%) (21.2%) Do you believe that your 0.000 My spouse/partner, most of 5 39 44 career pursuing will be the times (12.8%) (49.4%) (37.3%) negative affected after Equally 15 33 48 childbirth? (38.5%) (41.8%) (40.7%) Strongly agree 20 7 (5.9%) 27 Other family member 1 (2.6%) 0 (0.0%) 1 (0.9%) (23.0%) (13.3%) In case of emergency in your 0.112b Agree 41 25 66 work who will take care of (47.1%) (21.2%) (32.2%) the children?a Neither agree nor disagree 17 38 55 My spouse/partner, most of 22 57 79 (19.5%) (32.2%) (26.8%) the times (56.4%) (72.2%) (67.0%) Disagree 4 (4.6%) 31 35 Someone else (babysitter, in- 8 10 18 (26.3%) (17.1%) home childcare provider) (20.5%) (12.7%) (15.3%) Strongly disagree 5 (5.8%) 17 22 Other family member (14.4%) (10.6%) (continued on next page) 6 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Table 6 (continued ) Table 7 Questions Gender Total p-value Experience in neurosurgery. Questions Gender Total p- Female Male value Female Male Do you believe that pursuing 0.005 an academic career will be Would you mind your partner/ 0.832 negative affected after spouse to be a neurosurgeon? childbirth? Yes 27 35 62 Strongly agree 14 9 (7.6%) 23 (31.0%) (29.7%) (30.2%) (16.1%) (11.2%) No 60 83 143 Agree 39 32 71 (69.0%) (70.3%) (69.8%) (44.8%) (27.1%) (34.6%) If you had a chance would you 0.045 Neither agree nor disagree 14 37 51 consider being a (16.1%) (31.4%) (24.9%) neurosurgeon again? Disagree 12 27 39 Yes 56 91 147 (13.8%) (22.9%) (19.0%) (64.4%) (77.1%) (71.7%) Strongly disagree 8 (9.2%) 13 21 No 31 27 58 (11.0%) (10.2%) (35.6%) (22.9%) (28.3%) Is maternity/paternity an 0.000 Please provide a reason: obstacle in career Gender inequity 16 1 (3.7%) 17 0.000a pursuing? (51.6%) (29.3%) Yes 57 42 99 Lack of support 17 6 23 0.011 (65.5%) (35.6%) (48.3%) (54.8%) (22.2%) (39.7%) No 22 68 90 Long working hours 8 11 19 0.227 (25.3%) (57.6%) (43.9%) (25.8%) (40.7%) (32.8%) I prefer not to answer 8 (9.2%) 8 (6.8%) 16 Concerns about work/life 15 19 34 0.090 (7.8%) balance (48.4%) (70.4%) (58.6%) b Would you support more 0.059 Other 8 7 15 0.134 favorable conditions for (25.8%) (25.9%) (25.9%) colleagues with babies/ Are gender issues a 0.012 children? disadvantage in career Strongly agree 40 37 77 pursuing? (46.0%) (31.4%) (37.6%) Yes 70 76 146 Agree 35 47 82 (80.5%) (64.4%) (71.2%) (40.2%) (39.8%) (40.0%) No 17 42 59 Neither agree nor disagree 10 23 33 (19.5%) (35.6%) (28.8%) (11.5%) (19.5%) (16.1%) Please provide a reason: Disagree 2 (2.3%) 9 (7.6%) 11 Less accepted 38 28 66 0.034 (5.4%) (54.3%) (36.8%) (45.2%) Strongly disagree 0 (0.0%) 2 (1.7%) 2 (1.0%) Fewer opportunities 41 21 62 0.000 a (58.6%) (27.6%) (42.5%) The total number of participants having children is 118. b Many roles (scientist/spouse/ 31 39 70 0.396 Fisher exact test was applied. parent/friend) (44.3%) (51.3%) (48.0%) Pregnancy/child rearing 37 50 87 0.112 (52.9%) (65.8%) (59.6%) Patients often prefer a female 4 (5.7%) 1 (1.3%) 5 (3.4%) 0.194a starting over, the majority (71.7%) answered positively. According to our neurosurgeon Patients often prefer a male 30 27 57 0.364 participants, the most common reason for not choosing to be a neuro- neurosurgeon (42.9%) (35.5%) (39.0%) surgeon again was lifestyle and work/life balance (58.6%, Table 7). Other 5 (5.8%) 5 (4.2%) 10 0.011a Gender inequity and lack of support were important factors mainly for (4.9%) women (51.6% and 54.8%, respectively). Although in univariate analysis What would make your career age and professional status had an effect on these findings, they were not easier? More money 40 51 91 0.695 persistent in the multivariate model. Interestingly, 71.2% of participants (46.0%) (43.2%) (44.4%) view gender issues as a disadvantage in career pursuing. This hypothesis More time 50 66 116 0.826 was mostly supported by females (80.5% of female neurosurgeons, p < (57.5%) (55.9%) (56.6%) 0.05), while age and professional status were not associated (p > 0.05). More help (household, cleaning, 36 34 70 0.061 cooking, children, etc) (41.4%) (28.8%) (34.2%) The most common reason for this consideration was pregnancy/child- Another professional 33 36 69 0.266 rearing (59.6%, Table 7). After subgroup analysis, female neurosur- environment (37.9%) (30.5%) (33.7%) geons stated that they feel less accepted (54.3%) and have fewer op- Working in another country 23 30 53 0.870 portunities (58.6%) than their male counterparts (36.8% and 27.6%, (26.4%) (25.4%) (25.9%) respectively, p < 0.05). On the contrary, male neurosurgeons supported Other 3 (0.1%) 7 (0.1%) 10 0.523a (0.1%) that pregnancy/child-rearing (65.8%) and having many roles (51.3%) Would you recommend 0.005 are the main factors for viewing gender issues as a disadvantage in career neurosurgery to a female pursuing (Table 7, Fig. 2). These responses were not affected by any other medical student? factor in the multivariate regression model. In our study, the only Yes 62 61 123 (71.3%) (51.7%) (60.0%) parameter that could make a neurosurgeon's career easier, regardless of No 25 57 82 gender, was more free time (56.6%, Table 7). Most participants would (28.7%) (48.3%) (40.0%) recommend neurosurgery to a medical student (Table 7). Neurosurgeons Would you recommend 0.230 would recommend neurosurgery to both a female (60%) and more so to a neurosurgery to a male male (80%) medical student. However, although most women neuro- medical student? Yes 73 91 164 surgeons (71.3%) would recommend neurosurgery to a female medical (83.9%) (77.1%) (80.0%) student, only half of men (51.7%) would support this idea (p < 0.05). No 14 27 41 (16.1%) (22.9%) (20.0%) 7 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Fig. 2. Gender-associated factors negatively affecting the career pursuing. The most important parameter is pregnancy and child-rearing. However, after subgroup analysis, as it is illustrated by the chart, female neurosurgeons believe that less acceptance and fewer opportunities mainly contribute to this issue (p < 0.05), while males support that the presence of many roles and pregnancy are the main contributors (p > 0.05). 1.3. Discussion 17% attrition rate for female residents, compared with only 5.3% for males. They also noticed that the majority left the field within the first 1.3.1. The role of women in neurosurgery three years of training but stayed in medicine, pursuing anesthesia, Over the past century, neurosurgery has evolved and expanded in neurology or radiology (Renfrow et al., 2016). However, this study did various directions. The doctrine that women should be stay-at-home not attempt to ascertain reasons for attrition (Renfrow et al., 2016). mothers to raise their children, and manage their household has been Previously published studies showed that lifestyle considerations were slowly eroded over time. Knowing that more women than men are regarded as the main reason for attrition among women in general sur- graduating from medical schools, it is interesting that the number of gery (Jr Aufses et al., 1998; Dodson and Webb, 2005). Similar studies women entering traditionally male-dominated professions, such as implicate work-life balance as an essential factor, irrespectively of gender neurosurgery, is consequently increased (Abosch and Rutka, 2018). (Everett et al., 2007; Lambert and Holmboe, 2005). Gadjradj et al. stated Despite the rapidly increasing number of female neurosurgeons, the that female neurosurgeons are less satisfied with work-life balance than percentage of women neurosurgeons rising to leadership positions and males (p < 0.001) (Gadjradj et al., 2020). In our study, 43.5% of the pursuing an academic career still remains low. The first European women respondents stated satisfaction in terms of lifestyle-work balance, while neurosurgeons, emerged in the 1920s (Hernandez-Duran et al., 2021). 36.6% felt frustrated. Gender did not affect these findings in our study (p Currently, 12% of the European neurosurgical workforce is female, while > 0.05). However, in univariate analysis male gender, older age and only 6% of the leadership position is held by women (Steklacova et al., advanced professional status increased the probability for considering 2017; Wolfert et al., 2019). Thus, neurosurgeon's personal lifestyle and spare time adequate and satisfactory. Interestingly, our survey results work-family balance have recently come into sharp focus, as a potential identified lifestyle and work-life balance as the reasons for not choosing contributing factor to the existent mismatch between the increasing again neurosurgery, if starting over (58.6%). The importance of the number of female neurosurgeons and the stagnant number of female work-life balance may become even more important in both genders in leaders in neurosurgery. the near future. The geometrically increasing resignation rate of In our study we found that, neurosurgeons are supportive and helpful high-salary employees occurring mainly in the USA may well be a at home and work. However, women neurosurgeons take more re- reflection of a new trend for considering quality of life more important sponsibilities at home, especially in the child-rearing years. Furthermore, than a high salary or a sacrificing career. female neurosurgeons are more likely to live alone or stay childless more When it comes to what men and women value most in a job, most men often compared to their male colleagues. The probability of living alone prioritize having a high-paying job. On the other hand, most women are was negatively associated with age and advanced professional status in more concerned with having a flexible schedule with respect to lifestyle. univariate analysis. However, only the association with gender remained The gender pay gap is well known (Lean, 2022). Even in the same job, significant in multivariate analysis. Supportive facilities, flexible pro- women are still less paid than men in many countries. It has been esti- grams, universal life policies and presumably curbing of the social ste- mated that full-time, year-round workers, women in the U.S. make 17% reotypes are of importance to overcome gender inequities that women less than men, although among all workers the gender pay gap is an may still face in neurosurgery. alarming 27% (Institute for women’ s policy research and JobsStalled Progress, 2021). Likewise, in 2021 E. Cooney found that the salary gap 1.3.2. Work-life balance between male and female physicians adds up to $2 million in lifetime Despite the social stereotypes that have contributed to this situation, earnings (Cooney, 2021). In our data we found that male neurosurgeons many factors encourage men to be disproportionately more attracted to are the bread winners (73.3%), while females are not (37.0%), and this neurosurgery than women. Lifestyle is one of these factors. In 2016, difference reached the levels of statistical significance (p < 0.05). The Renfrow et al. analyzed all residents who matched into neurosurgery fact that females mainly prefer part time jobs and flexible working-hour between 2000 and 2009 according to the databases from the American programs or the stereotype that it is socially accepted for a woman to Association of Neurological Surgeons (AANS) and the American Board of have a complementary role in the household income could be the reason Neurological Surgery (ABNS) (Renfrow et al., 2016). The authors found for this finding. 8 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 1.3.3. Gender inequities Difficulties with pregnancy, breastfeeding, and childcare issues may Several factors play a vital role in specialty choice. It is widely known all contribute to surgeon burnout, affect job satisfaction, and contribute that neurosurgery is one of the most demanding surgical subspecialties. to challenges in maintaining the future surgical workforce. We found that Perceived biological differences between men and women may have a women neurosurgeons seem to have more childcare responsibilities than negative impact on retention and/or deter them from choosing a men. However, recent studies have shown that men value parenting and neurosurgery career. Pregnancy and child-rearing can be a perception of are actively involved in their children's care (Huerta et al., 2014). weakness. A recent survey, in which all continents were represented, Although 43% of fathers had never changed a diaper/nappy two decades reported that female neurosurgeons do not feel they are equally treated ago, today this is true for only 3% of fathers (Jones and Mosher, 2013). by their supervisors (Gadjradj et al., 2020). The authors found that 83.3% Therefore, there has been increasing interest in paternity leave. It seems of women strongly believe that their gender is a disadvantage in career that fathers who take paternity leave are more actively involved in the progression, while only 10.3% of men shared the same feeling (Gadjradj child's care (Huerta et al., 2014). Although historically there has been et al., 2020). more emphasis on maternity leave, parental leave is also important for In our current study, 71.2% of participants answered that gender is- both parents. We found that regardless of gender, 44.9% used a parental sues constitute a disadvantage in the pursuit of a neurosurgical career. leave of absence. However, while most of men took time out from clinical This statement was mainly expressed by females (80.5%). The most duties for less than one month, the majority of their spouses/partners common reason for this consideration was pregnancy and child-rearing used a quite longer maternity leave of at least seven-month duration (p < (59.6%). Women neurosurgeons are more likely to be unmarried 0.05). (37.9%) or childless (55.2%), have fewer children (46.2%) or postpone having children due to lack of support (12.5%) compared with their male 1.3.5. Contribution in household responsibilities counterparts (14.4%, 33.1%, 22.8%, and 5.1%, respectively). In 2021, Housework obligations constitute another parameter resulting in K€osedagli et al. described that the careers of women and men working in strain, frustration, and displeasure with work-life balance. Women spend the financial sector evolve in parallel until the birth of their first child. more time performing household duties than men. We found that female Their career trajectories then sharply diverge immediately after child- neurosurgeons spend much more time cleaning, cooking, and house- birth, and never converge again (K€ osedagli et al., 2021). Gadjradj et al. keeping than men (Table 5). Moreover, male neurosurgeons admitted presented that female neurosurgeons were less likely to be married and that their partners/spouses are burdened more (Table 5). To our have children and also be of older age when having children (p < 0.001) knowledge this is the first study assessing the contribution of neurosur- (Gadjradj et al., 2020). We found that 65.5% of women and 35.6% of geons in household activities. Increased home and family re- men neurosurgeons report parenthood as an obstacle in career pursuing sponsibilities, work environment biases and harassment, long years of and academic productivity. difficult training, endless hours in the operating theatre, and inflexible Certain groups in the neurosurgical workforce, remain underrepre- work environment are common factors that negatively affect personal sented owing to systemic barriers based on social identities and catego- lifestyle, overall job satisfaction and life success. Therefore, they influ- rizations, including gender, race, ability status, and others (Kim et al., ence work-family balance and promote burnout. 2021). In his 2004 bestseller, “Moneyball”, Michael Lewis wrote: “What begins as a failure of the imagination ends as a market inefficiency: when you 1.3.6. Social obstacles and stereotypes - the glass ceiling rule out an entire class of people from doing a job simply by their appearance, Women surgeons potentially face gender issues not only during you are less likely to find the best person for the job” (Lewis, 2022). Diversity training but also in practice. They often express thoughts of not feeling may well strengthen neurosurgery. Undoubtedly, attracting people with recognized or being less accepted and less appreciated by their supervi- different strengths, qualities, experience, and backgrounds unleashes sors and patients. They also feel they have fewer opportunities to get new sources of talent and creativity. leadership positions or pursue an academic career. In certain parts of the world, women are still less paid than men when working in similar jobs, 1.3.4. Legislation and policies while they receive different rewards for similar achievements (Gadjradj Most of the modifiable factors that impede neurosurgeons from et al., 2020; Furnas et al., 2018; Halperin et al., 2010; Jagsi et al., 2006; having children, especially during residency, are associated with policies, Jonasson, 2002; Venes and Parent, 2006). In 2008, the white paper including lack of universal leave policy and lack of flexibility (Gadjradj emphasized that gender disparities are magnified in traditionally et al., 2020; Altieri et al., 2019). Personnel issues, such as strain on the male-dominated environments, such as neurosurgery, and underscored residency program and lack of support from peers/faculty are of impor- that women are rarely advanced into leadership or chair positions within tance. In 2019, Altieri et al. noted that many residents in the surgical field neurosurgery (WINS White Paper Committee: et al., 2008). Many of these do not feel support in taking parental leave by either other residents or problems are not exclusive to neurosurgery but are ingrained and esca- the faculty (>60%) (Altieri et al., 2019). The authors pointed out that the lated over time. To overcome these obstacles, the authors focused on lack of a universal leave policy, strain and lack of flexibility in the resi- leadership training, negotiating skills, networking, defined policies on dency program, loss of education/training time, and lack of support are harassment and discrimination, and development of female role models the main obstacles to taking a parental leave during residency (Altieri and mentors. They believe that these recommendations are likely to et al., 2019). In our survey, most participants would support more benefit all neurosurgeons, irrespective of gender, and ensure the viability favorable conditions for colleagues with babies/children (77.6%). In a of neurosurgery in the future (WINS White Paper Committee: et al., 2008; recent study, only 34.9% of participants reported having formal surgical Wright et al., 2003). program maternity leave policies (Rangel et al., 2018). Measures like Role strain for female professionals, academic responsibilities, these are of importance especially for single parents. The competing discrimination and harassment, socio-psychological issues because of demands at work and at home for solo parents are even greater. persistent gender stereotypes, mentoring, and role models are also factors Frequently, single parents have to stay up late with a sick child or stay responsible for the glass ceiling (Woodrow et al., 2006). We found that longer at work, face an emergency, undertake home responsibilities and men held leadership and academic positions more frequently than enforce house rules, alone. Gadjradj et al. found that female neurosur- women (Table 2); however, this finding was not statistically significant. geons are more likely to break-up or divorce (p < 0.001) (Gadjradj et al., In our data, most neurosurgeons stressed that there is still a theme of 2020). Medical training (44.6%) and/or career (48.6%) demands mainly gender inequity in career pursuit. This hypothesis was mainly supported contributed to this situation (Gadjradj et al., 2020). Seven neurosurgeons by women (80.5%) in our study. Gadjradj et al. reported that female (5.9%) in our study indicated that they were single parents, while all of neurosurgeons were less likely to choose again a career in neurosurgery them, most probably by coincidence, single mothers. (Gadjradj et al., 2020). They also found that all respondents in their study 9 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 were less likely to recommend a neurosurgical career to a daughter than Acknowledgements to a son (p < 0.001) (Gadjradj et al., 2020). In our communication, gender inequity was among the main reasons for not choosing a career as We thank the EANS for distributing this survey to the EANS neurosurgeon, especially among females. We also found that although Community. most women neurosurgeons (71.3%) would recommend neurosurgery to a female medical student, only half of men (51.7%) would do so (p < Appendix A. Supplementary data 0.05). It remains controversial if gender discrimination in neurosurgery Supplementary data to this article can be found online at https://doi. constitutes a well-preserved myth. The observed underrepresentation of org/10.1016/j.bas.2022.101100. women in the neurosurgical community could be related to social factors other than gender discrimination itself. Potentially addressable social References issues in different countries and different cultures are often ignored. Abosch, A., Rutka, J.T., 2018. Women in neurosurgery: inequality redux. J. Neurosurg. 129, 277–281. https://doi.org/10.3171/2018.4.JNS172878. 1.3.7. Study limitations Altieri, M.S., Salles, A., Bevilacqua, L.A., Brunt, L.M., D Mellinger, J., Gooch, J.C., Our study has certain limitations. Firstly, the total number of partic- Pryor, A.D., 2019. Perceptions of surgery residents about parental leave during ipants is relatively small and some countries have a limited representa- training. JAMA Surg. 154, 1–7. https://doi.org/10.1001/jamasurg.2019.2985. Cooney, E., 2021. Salary Gap between Male and Female Physicians Adds up to $2 Million tion. Thus, subgroup analysis based on nationality was not performed in Lifetime Earnings. https://www.statnews.com/2021/12/06/male-female-phys due to the limited number of participants. Despite that the heterogeneity ician-salaries-gap-2-million-lifetime-earnings/. (Accessed 6 December 2021). of our study population could be a selection bias, the current data is accessed. Dodson, T.F., Webb, A.L.B., 2005. Why do residents leave general surgery? The hidden sufficient to give a general picture of European neurosurgeons' perspec- problem in today's programs. Curr. Surg. 62, 128–131. https://doi.org/10.1016/ tives, and a broad spectrum of opinions is presented, highlighting exactly j.cursur.2004.07.009. our study's contribution to the pertinent literature. Everett, C.B., Helmer, S.D., Osland, J.S., Smith, R.S., 2007. General surgery resident attrition and the 80-hour work week. Am. J. Surg. 194, 751–757. https://doi.org/ Secondly, we could not calculate the actual response rate due to the 10.1016/j.amjsurg.2007.08.033. questionnaire's distribution on social media. Moreover, the female to Furnas, H.J., Garza, R.M., Li, A.Y., Johnson, D.J., Bajaj, A.K., Kalliainen, L.K., male ratio in our study was much higher than the reported one world- Weston, J.S., Song, D.H., Chung, K.C., Rohrich, R.J., 2018. Gender differences in the wide. The fact that half of our participants were women possibly in- professional and personal lives of plastic surgeons. Plast. Reconstr. Surg. 142, 252–264. https://doi.org/10.1097/PRS.0000000000004478. troduces a selection bias. Gadjradj, P.S., S Matawlie, R.H., Voigt, I., Harhangi, B.S., Vleggeert-Lankamp, C.L.A.M., It also needs to be pointed out that, this survey was conducted during 2020. Gender Differences between male and female Neurosurgeons: is there equality the Covid-19 pandemic. The psychological impact of the pandemic for all? World Neurosurg. 136, 348–356. https://doi.org/10.1016/ j.wneu.2019.11.178. cannot be accurately accounted but is likely to be significant and may Halperin, T.J., Werler, M.M., Mulliken, J.B., 2010. Gender differences in the professional affect some groups or one gender more than another. Therefore, we and private lives of plastic surgeons. Ann. Plast. Surg. 64, 775–779. https://doi.org/ should state that this situation might indirectly affect answers to ques- 10.1097/SAP.0b013e3181b02292. Hernandez-Duran, S., Murphy, M., Kim, E., Al-Shehhi, N., Broekman, M., de Praeter, M., tions dealing with feelings, emotions, and perspectives. Dubuisson, A., Emery, E., Gazioglu, N., Grossman, R., Janssen, I.K., Karampouga, M., Khorbaladze, L., Lambrianou, X., Lippa, L., Magnadottir, H., Mihaylova, S., Pajaj, E., 1.4. Conclusions Rabie, K., Rodríguez-Hernandez, A., Tasiou, A., Vayssiere, P., Rosseau, G., 2021. European women in neurosurgery: I - a chronology of trailblazers. J. Clin. Neurosci. 86, 316–323. https://doi.org/10.1016/j.jocn.2021.01.026. In our study we found that neurosurgeons contribute a lot to house- Huerta, M.C., Adema, W., Baxter, J., Han, W.J., Lausten, M., Lee, R.H., Waldfogel, J., work and child-rearing. Females have more responsibilities at home and 2014. Fathers' leave and fathers' involvement: evidence from four OECD countries. Eur. J. Soc. Secur. 16, 308–346. https://doi.org/10.1177/138826271401600403. are in greater need of support and spare time to organize and plan the IBM Corp, 2011. IBM SPSS Statistics for Windows [Computer Software]. Armonk, New work and home activities, especially during the child-rearing years. York. Also, we found that female neurosurgeons more often live alone, and Institute for women’s policy research, Jobs, Lost, Stalled Progress, 2021. The Impact of are less likely to have children compared to their male colleagues. It is the “She-Cession” on Equal Pay. https://iwpr.org/wp-content/uploads/2021 /09/Gender-Wage-Gap-in-2020-Fact-Sheet_FINAL.pdf/. (Accessed 27 April 2022). accepted that career-pursuing females usually have fewer children and accessed. are more likely to be of older age when having them. The early middle Jagsi, R., Guancial, E.A., Worobey, C.C., Henault, L.E., Chang, Y., Starr, R., Tarbell, N.J., age/child-rearing years are remarkably stressful as they are crucial for a Hylek, E.M., 2006. The "gender gap" in authorship of academic medical literature - a 35-year perspective. N. Engl. J. Med. 355, 281–287. https://doi.org/10.1056/ neurosurgeon's career and simultaneously intensive at home. NEJMsa053910. Women in neurosurgery seem to be still facing gender inequities. The Jonasson, O., 2002. Leaders in American surgery: where are the women? Surgery 131, value of our study is to trigger a broad and frank discussion regarding 672–675. https://doi.org/10.1067/msy.2002.124880. Jones, J., Mosher, W.B., 2013. Division of vital statistics, fathers' involvement with their gender issues in the neurosurgical community. It has to be emphasized, children: United States, 2006-2010. Natl. Health Stat. Rep. 71, 1–21. PMID: however, that gender inequities in neurosurgery represents just the tip of 24467852. the iceberg. Actually, it is just a part of an international, wide-spectrum, Jr Aufses, A.H., Slater, G.I., Hollier, L.H., 1998. The nature and fate of categorical surgical residents who "drop out. Am. J. Surg. 175, 236–239. https://doi.org/10.1016/s0002- perplex problem based on a variety of socio-economic, cultural, and 9610(97)00292-4. religious factors among different countries, around the world. We believe Kim, E.E., Klein, A.L., Lartigue, J.W., Hervey-Jumper, S.L., Rosseau, G., 2021. Diversity in that a thorough and sincere discussion of the problem may well lead to its neurosurgery. World Neurosurg. 145, 197–204. https://doi.org/10.1016/ j.wneu.2020.08.219. solution. K€osedagli, B.Y., 2021. Gender equality in the finance sector. Closing gaps or another “old boys club”. In: Ince Yenilmez, M., Huyugüzel Kişla, G.S. (Eds.), The Economics of Disclosure Gender Equality in Labour Market. Taylor & Francis Ltd., UK, pp. 57–72. Lambert, E.M., Holmboe, E.S., 2005. The relationship between specialty choice and gender of U.S. medical students, 1990-2003. Acad. Med. 80, 797–802. https:// The authors report no conflict of interest concerning the materials or doi.org/10.1097/00001888-200509000-00003. methods used in this study or the findings specified in this paper. Lean, In, 2022. Women Are Paid Less than Men – and the Gap Is Closing Too Slowly. https://leanin.org/equal-pay-data-about-the-gender-pay-gap/. (Accessed 27 April 2022). accessed. Funding Lewis, Michael, 2022. Moneyball. https://michaellewiswrites.com/index.html#m oneyball/. (Accessed 5 April 2022). accessed. None. Rangel, E.L., Smink, D.S., Castillo-Angeles, M., Kwakye, G., Changala, M., Haider, A.H., Doherty, G.M., 2018. Pregnancy and motherhood during surgical training. JAMA Surg. 153, 644–652. https://doi.org/10.1001/jamasurg.2018.0153. 10 X. Lambrianou et al. Brain and Spine 2 (2022) 101100 Renfrow, J.J., Rodriguez, A., Liu, A., Pilitsis, J.G., Samadani, U., Ganju, A., Germano, I.M., recruitment and retention of women in neurosurgery. J. Neurosurg. 109, 378–386. Benzil, D.L., Quintero Wolfe, S., 2016. Positive trends in neurosurgery enrollment https://doi.org/10.3171/JNS/2008/109/9/0378. and attrition: analysis of the 2000-2009 female neurosurgery resident cohort. Wolfert, C., Rohde, V., Mielke, D., Hernandez-Duran, S., 2019. Female neurosurgeons in J. Neurosurg. 124, 834–839. https://doi.org/10.3171/2015.3.JNS142313. Europe - on a prevailing glass ceiling. World Neurosurg. 129, 460–466. https:// Steklacova, A., Bradac, O., de Lacy, P., Benes, V., 2017. E-WIN Project 2016: evaluating doi.org/10.1016/j.wneu.2019.05.137. the current gender situation in neurosurgery across Europe - an interactive, multiple- Woodrow, S.I., Gilmer-Hill, H., Rutka, J.T., 2006. The neurosurgical workforce in North level survey. World Neurosurg. 104, 48–60. https://doi.org/10.1016/ America: a critical review of gender issues. Neurosurgery 59, 749–758. https:// j.wneu.2017.04.094. doi.org/10.1227/01.NEU.0000232671.44297.DF. Venes, J.L., Parent, A.D., 2006. Women in neurological surgery. Matson memorial lecture. Wright, A.L., Schwindt, L.A., Bassford, T.L., Reyna, V.F., Shisslak, C.M., St Germain, P.A., J. Neurosurg. 104, 227–232. https://doi.org/10.3171/ped.2006.104.4.227. Reed, K.L., 2003. Gender differences in academic advancement: patterns, causes, and WINS White Paper Committee:, Benzil, D.L., Abosch, A., Germano, I., Gilmer, H., potential solutions in one US College of Medicine. Acad. Med. 78, 500–508. https:// Maraire, J. Nozipo, Muraszko, K., Pannullo, S., Rosseau, G., Schwartz, L., Todor, R., doi.org/10.1097/00001888-200305000-00015. Ullman, J., Zusman, E., 2008. The future of neurosurgery: a white paper on the 11