TYPE Original Research PUBLISHED 07 December 2022 DOI 10.3389/fonc.2022.1005130 Gender-related differences in OPEN ACCESS career development among EDITED BY Sarah M. Temkin, National Institutes of Health (NIH), gynecologic oncology surgeons United States REVIEWED BY in Europe. European Network of Pauline Wimberger, Technical University Dresden, Germany Deborah Verran, Young Gynecologic Consultant, Sydney, NSW, Australia *CORRESPONDENCE Oncologists’ Survey based data Tanja Nikolova nikolovatanja@gmail.com Tanja Nikolova 1*, Michaela Bossart 2, Joanna Kacperczyk-Bartnik 3, SPECIALTY SECTION This article was submitted to Zoia Razumova 4, Alexandra Strojna 5, Nicolò Bizzarri 6, Gynecological Oncology, a section of the journal Andrei Pletnev 7, Natalia R. Gómez-Hidalgo 8, Frontiers in Oncology Charalampos Theofanakis 9, Maximilian Lanner 10, Ilker Selcuk 11, RECEIVED 27 July 2022 Alexander Shushkevich 12, Chelariu-Raicu Anca 13, ACCEPTED 15 November 2022 PUBLISHED 07 December 2022 Natasha Nikolova 14, Nicole Concin 15,5 and Kamil Zalewski 16 CITATION 1 Klinikum Mittelbaden, Academic Teaching Hospital of Heidelberg University, Baden-Baden, Germany, Nikolova T, Bossart M, 2 Department of Obstetrics and Gynecology, St. Josefskrankenhaus, Freiburg, Germany, Kacperczyk-Bartnik J, Razumova Z, 3 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland, Strojna A, Bizzarri N, Pletnev A, 4 Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden, Gómez-Hidalgo NR, Theofanakis C, 5 Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany, Lanner M, Selcuk I, Shushkevich A, 6 Unità Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Anca C-R, Nikolova N, Concin N and Salute Pubblica, Fondazione Policlinico Universitario a Gemelli, Rome, Italy, 7 Department of Zalewski K (2022) Gender-related Obstetrics and Gynecology, University of Zielona Gora, Zielona Gora, Poland, 8 Gynecological differences in career development Oncology Department, Vall d’Hebron Hospital, Autonoma University of Barcelona, Barcelona, among gynecologic oncology Spain, 9 Department of Gynecological Oncology, General Hospital of Athens Alexandra, Athens, surgeons in Europe. European Greece, 10 Department of Gynecology, Private Hospital Villach, Villach, Austria, 11Department of Network of Young Gynecologic Gynecologic Oncology, Ankara City Hospital, Ankara, Turkey, 12 Department of Surgery, Institute of Oncologists’ Survey based data. Biology and Medicine, Taras Shevchenko National University of Kyiv, Kyiv, Ukraine, 13 Department of Front. Oncol. 12:1005130. Obstetrics and Gynecology, University Hospital, Ludwig-Maximillians-University, Munich, Germany doi: 10.3389/fonc.2022.1005130 & German Cancer Consortium and German Cancer Research Center, Heidelberg, Germany, COPYRIGHT 14 Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy, 15 Department © 2022 Nikolova, Bossart, Kacperczyk- of Gynecology and Obstetrics, Innsbruck Medical University, Innsbruck, Austria & Department of Bartnik, Razumova, Strojna, Bizzarri, Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany, 16 Department Pletnev, Gómez-Hidalgo, Theofanakis, Gynecologic Oncology, Holycross Cancer Center, Kielce, Poland Lanner, Selcuk, Shushkevich, Anca, Nikolova, Concin and Zalewski. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other Introduction: Gender-related differences in career development are well known forums is permitted, provided the original author(s) and the copyright issues in various professions. An international survey on gender-related owner(s) are credited and that the differences was performed among young gynecologic oncology surgeons in original publication in this journal is cited, in accordance with accepted Europe to identify potential gender inequalities in career development. academic practice. No use, distribution or reproduction is Material and methods: A survey on demographics, clinical and academic permitted which does not comply with these terms. working environment, family/parenting, career development, salary and leadership was sent to all members of the European Network of Young Gynecologic Oncologists (ENYGO), which is a network within the European Frontiers in Oncology 01 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 Society of Gynecologic Oncology (ESGO). Gynecologic oncology surgeons and obstetricians/gynecologists who actively work in this field in Europe were included in the study. Results: Responses were analyzed from 192 gynecologic oncology surgeons of whom 65.1% (125/192) were female (median age 37, IQR: 34 - 42) and 34.9% (67/192) were male (median age 38, IQR: 36 - 41). Male reported to perform a median of 15 and female a median of 10 operations per month (p = .007). Among female, 24.8% had a leadership position vs. 44.8% among male, crude OR = 2.46, 95% CI 1.31-4.62, p<.01. When stratifying for age under 41 and having children, 36.7% of male and 5.6% of female had a leadership position, adjusted OR 10.8, 95% CI 3.28-35.64, p<.001. A significantly higher proportion of female compared to male believed they earned less than their gender counterparts at the same clinical position and with same qualifications (30.4% vs. 2.5%, p<.001). There was not a statistically significant gender difference in the academic qualification PhD degree or professorship (p = .92 and p = .64, respectively). In the previous year, male published more peer- reviewed articles than female (median 3 vs. median 2; p = .017). Conclusion: This first comprehensive survey on gender-differences in gynecologic oncology in Europe revealed that there are gender gaps concerning several aspects during the critical time of career development in the young generation of gynecologic oncology surgeons. These gender gaps are particularly reflected by a lower rate of female leadership positions. ENYGO and ESGO are dedicated to work on solution to overcome the identified obstacles and to support closing gender gaps. KEYWORDS gender-related differences, gender inequalities, gynecologic oncology surgeons, career development, leadership, salary Introduction On the other side the published literature indicates that in the field of medicine female still face manyfold career barriers in According to the report of the Organization for Economic comparison to their male colleagues. Female are reported to have Cooperation and Development countries (OECD), almost half of less opportunities to research and to publish, are promoted more all medical doctors in 2019 were female (1). Female accounted slowly and at a lower rate e.g. for professorship positions and are for more than half of students entering PhD programs in the less paid than their male counterparts (3–9). Studies performed United States (2). Based on membership data of the European among medical professionals in different fields show that Society of Gynecological Oncology (ESGO), the proportion of although female participation in medical schools and hospitals female gynecologic oncologists has been constantly increasing in is increasing, male professionals still dominate at senior leading the last decade. While in 2009 more than two thirds of members positions (10, 11). were male, the gender distribution reached parity in 2019. An To our knowledge there is not any published data on gender- even faster growing trend is evident among the younger related differences in career development among gynecologic generation of gynecologic oncologists in Europe. According to oncology surgeons in Europe. the membership directory of the European Network of Young We performed a comprehensive survey consulting the young Gynecologic Oncologists (ENYGO), which is a network of generation of gynecologic oncology surgeons and specialists in ESGO comprising the young generation of the gynecologic gynecology and obstetrics with a major focus on gynecologic oncology surgeons, 2/3 of members were female in 2019. oncology surgery, who are working in academic and Frontiers in Oncology 02 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 nonacademic surgical centers. The aim of this survey was to and Mann-Whitney U test. The Cochran-Mantel-Haenszel test of investigate potential gender differences and potential obstacles homogeneity was used in cases where controlling for gender or during the time of career development. age with other significant factors had to be explored. All tests were two-tailed at the level of statistical significance a = 5%. Methods Results A survey consisting of 85 questions was designed and approved by the Institutional Review Board at the Medical Description of the study population School, University in Kielce, Poland (Number: 65/2021). The questionnaire consisted of questions related to demographics; The survey link was sent to 745 ENYGO members. A total of clinical and academic working environment; family and 230 recipients replied after the survey was launched by the third parenting; career development; leadership including clinical time (response rate of 30.9%). Of them, 38 (16.5%) respondents director, head of department and head of division, as well as were excluded, as they did not meet the inclusion criteria (31 salary. The questions validity was thereafter assessed through a were not working in Europe, 7 were not actively working in the review of 12 ENYGO members who were selected to represent field of gynecologic oncology surgery). Thus, answers from a the different sociodemographic characteristics (gender, age, total of 192 respondents were included in the final analysis with nationality, country of practicing, partner status, children, and a median age 37 years (IQR: 35 - 42). Of them, 132 (68.6%) were sexual orientation). Each reviewer assessed the questions and gynecologic oncology surgeons, either subspecialists who have response options to ensure their clearness and inclusivity with completed their training (n=84, median age 40 years, IQR: 36 - regards to diverse life and professional experiences. 44) or fellows in training (n=48, median age 36 years, IQR: 33 - ENYGO is a network within ESGO, which comprises of 38), and 60 (31.4%) were specialists in gynecology and obstetrics subspecialists in gynecologic oncology surgery who are ≤40 who were actively working as surgeons in gynecologic oncology years of age, and of fellows in subspeciality training for (median age 37 years, IQR: 34 - 42). Table 1 shows the general gynecologic oncology surgery (all fellows in training demographic characteristics of the respondents. independent of age), as well as of specialists in gynecology and obstetrics ≤40 who are actively working in the field of gynecologic oncology surgery. The survey was administrated anonymously to Clinical working environment all ENYGO members in electronic format via the survey tool and leadership “SurveyMonkey” (SurveyMonkey Inc. Palo alto, CA, USA). The first participating request was sent in October 2019. It The obtained data about the clinical working environment was promoted during the ESGO conference in Athens in are presented in Table 2. November of 2019 and after that, launch was repeated in There was a significant difference in the number of reported January and February of 2020. The online software allowed operative cases per month between male and female. Male reported respondents to complete the survey without answering all the a median of 15 and female a median of 10 cases per month questions, hence each question was not necessarily answered by (U (Nmale= 29, Nfemale= 71) = 677, z = -2.71, p = .007, (h2 = all the respondents. .072). The number of night shifts per month did not differ between Inclusion criteria for distribution of this survey were male and female (median of 4 for both genders). ENYGO members who were practicing in Europe at the time The data about the reported leadership positions in male of survey. Respondents who were not actively working in the versus female, as well as the subsequent stratifications are field of gynecologic oncology surgery and were not practicing in presented in Table 3. Europe were excluded from the study. There was a significant difference in reported leadership positions between male and female. 44.8% (30/67) of male compared to 24.8% (31/125) of female reported to have a Statistical analysis leadership position, (crude OR 2.46, 95% CI 1.31-4.62, p = .005, c2 (1, N = 192) = 8.03, small effect size f = .205). Statistical data analysis was performed using statistical When stratified for age under 41 and having children, the software SPSS version 26. Descriptive statistics was used to gender gap was the most pronounced with 36.7% (11/30) of male summarize the results of the questionnaire. As not all the compared to 5.6% (2/36) of female having a leadership position questions were answered by all the respondents, the percentage (adjusted OR 10.8, 95% CI 3.28-35.64, p<.001, cCMHtest 2 (1, N = was calculated using a number of respondents to the specific 137) = 19.3, p<.001, cBDtest (3, N = 137) = 3.77, p = .29). 2 question as a denominator. Categorical and ordinal data Among respondents with children, 96.4% (53/55) of female and associations were tested using Chi-squared or Fisher’s exact test 75.8% (25/33) of male used parental leave. 58.5% (31/53) of female Frontiers in Oncology 03 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 TABLE 1 Demographic characteristics. Male Female Total n % n % n % Gender 67 34.9% 125 65.1% 192 Age ≤ 30 0 0.0% 17 13.6% 17 8.9% 31-40 49 73.1% 72 57.6% 121 63.0% 41-50 11 16.4% 30 24.0% 41 21.4% 51-60 5 7.5% 6 4.8% 11 5.7% > 61 2 3.0% 0 0.0% 2 1.0% Marital Status Single 4 8.3% 20 23.0% 24 17.8% Married/partner 43 89.6% 64 73.6% 107 79.3% Divorced 1 2.1% 3 3.4% 4 3.0% Children Yes 38 79.2% 57 64.0% 95 69.3% No 10 20.8% 32 36.0% 42 30.7% Number of Children 0 29 43.3% 68 54.4% 97 50.5% 1 13 19.4% 29 23.2% 42 21.9% 2 17 25.4% 22 17.6% 39 20.3% ≥3 8 11.9% 6 4.8% 14 7.3% Parental leave Yes 25 75.8% 53 96.4% 78 88.6% No 8 24.2% 2 3.6% 10 11.4% TABLE 2 Clinical characteristics. Male Female Total p - value n % n % n % Working in academic oncology center .76 Yes 42 85.7% 72 83.7% 114 84.4% No 7 14.3% 14 16.3% 21 15.6% Level of training .59 Fellow in Gyn. Onc. 14 20.9% 34 27.2% 48 25.0% Gyn. Onc. Surgeon 32 47.8% 52 41.6% 84 43.8% Specialist in Ob/Gyn. 21 31.3% 39 31.2% 60 31.3% Number of operative cases per month .006 <5 1 2.2% 9 10.5% 10 7.5% 5-10 9 19.1% 33 38.4% 42 31.6% > 10 37 78.7% 44 51.1% 81 60.9% Number of night shifts per month .64 0 4 8.5% 9 10.7% 13 9.9% 1-4 19 40.4% 42 50.0% 61 46.6% 5-9 18 38.3% 25 29.8% 43 32.8% ≥ 10 6 12.8% 8 9.5% 14 10.7% Frontiers in Oncology 04 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 TABLE 3 Leadership position analysis. Male Female Crude OR (95% CI) p - value c2 Effect size (f) 44.8% (30/67) 24.8% (31/125) 2.46 (1.31-4.62) .005 (1, N=192) = 8.03 .205 Stratified 2 2 Male Female Adjusted OR (95% CI) p - value cCMHtest p - value cBDtest p - value “Being married/living with a partner” 48.8% (20/41) 17.5% (11/63) 3.89 (1.75-8.65) .001 (1, N = 139) = 11.6 .001 (1, N = 139) = 0.64 .425 “Being married to a medical doctor/living with a partner who is a medical doctor” 45.8% (11/24) 24.3% (9/37) 3.37 (1.46-7.75) .004 (1, N = 115) = 8.58 .003 (1, N = 115) = 0.46 .496 Age under 41 years 32.7% (16/49) 13.5% (12/89) 3.11 (1.53-6.36) .002 (1, N = 192) = 10.3 .001 (1, N = 192) = 0.001 .993 Parental status (having children vs. not having) 50% (19/38) 19.3% (11/57) 3.91 (1.75-8.73) .001 (1, N = 137) = 11.6 .001 (1, N = 137) = 0.11 .74 Age under 41 and having children 36.7% (11/30) 5.6% (2/36) 10.8 (3.28-35.64) <.001 (1, N = 137) = 19.3 <.001 (3, N = 137) = 3.77 .29 used parental leave for a year or less (6 weeks to 12 months) and 8.9% (7/79) of female believed that their position was higher. On 41.5% (22/53) for more than a year (up to a max of 3 years). 66.7% the other side, 87.5% (35/40) of male believed that their achieved (16/24) of male used parental leave for a maximum of six weeks (1 clinical position was the same as their female counterparts with to 6 weeks) and 33.3% (8/24) for more than six weeks (up to a approximately same experience and age, 12.5% (5/40) believe maximum of one year). Among both genders, there was no that it was higher, and none believed that their position was association between the leadership position and the length of lower (c2 (2, N = 119) = 26.4, p<.001, medium to strong effect parental leave (for female: c2 (1, N = 53) = 0.298, p = .56; for size V = .471). male: c2 (1, N = 24) = 2.1, p = .15). On the question: “Are you happy with your current clinical The data on the question: “Is your achieved clinical position achievements?”, more than half of male respondents, i.e. 53.8% (21/ same, higher or lower in comparison to your opposite gender 39), declared that they were happy, and 46.2% (18/39) declared that colleagues with the same experience and at approximately same they were not happy with their current clinical achievements, while age?” is presented in Figure 1. There was a significant medium to 32.5% (26/80) of female respondents declared their happiness and strong association between the perception of having achieved the more than half, i.e. 67.5% (54/80), their unhappiness with the “adequate” clinical position and gender. 45.6% (36/79) of female current clinical achievements (OR 2.42, 95% CI 1.11-5.31, p = .025, believed that their achieved clinical position was lower than the c2 (1, N = 119) = 4.99, small effect size f = .205). one of their male counterparts with approximately the same 30.4% (24/79) of female and 2.5% (1/40) of male believed experience and age, 45.6% (36/79) believed it was the same, and that their salary was lower in comparison with their gender FIGURE 1 Is your achieved clinical position same, higher or lower in comparison to your opposite gender colleagues with the same experience and at approximately same age? Frontiers in Oncology 05 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 counterparts at the same position and clinical/academic Parental leave duration was no adverted factor for female to qualifications, while 97.5% (39/40) of male and 69.6% (55/79) hold an academic qualification (PhD degree and/or of female believed that their salary was the same or higher (OR professorship; c2 (2, N = 52) = 2.71, p = .258). 17.01, 95% CI 2.21-131.14, p<.001, c2 (1, N = 119) = 12.44, There was a significant small to intermediate effect between medium effect size f = .323). number of peer reviewed publications in the previous year and the gender. On average, male had more publications (median = 3) in the previous year than female (median = 1). The difference was Academic working environment significant U (Nmale= 46, Nfemale= 86) = 1,488, z = -2.38, p = .017, h2 = .042. When stratified for having children, the small to Data about the academic working environment are intermediate effect between number of publications in the presented in Table 4. previous year and gender remained. Male with children 55.2% (37/67) of female respondents and 62.9% (22/35) of published more (median = 2) than female with children male respondents hold a PhD title (c2 (1, N = 102) = 0.55, p = .92, (median = 1) in the previous year. The difference was adjusted for Bonferroni correction). More male, 51.9% (14/27), significant U (Nmale= 36, Nfemale= 55) = 741.5, z = -2.06, p = .04, than female, 40% (20/50), reported to have a professor position. h2 = .043. However, this difference was not statistically significant (c2 (1, N = A comparable number of males and females have received at 77) = 0.99, p = .64, adjusted for Bonferroni correction). least one medical grant/funding in the previous five years 45% TABLE 4 Academic characteristics. Male Female Total p - value n % n % n % Academic qualifications: .59 None 13 26.5% 30 34.5% 43 31.6% PhD 22 44.9% 37 42.5% 59 43.4% Professor 14 28.6% 20 23.0% 34 25.0% Professorship: .11 Assistant Professor 3 21.4% 8 40.0% 11 32.4% Associate Professor 10 71.4% 7 35.0% 17 50.0% Full Professor 1 7.2% 5 25.0% 6 17.6% Did you have publications in the previous year? .30 Yes 36 78.3% 60 69.8% 96 72.7% No 10 21.7% 26 30.2% 36 27.3% Number of full-text publications as first and last author in your medical career: .024 0 17 37.0% 35 40.7% 52 39.4% 1-3 18 39.1% 45 52.3% 63 47.7% 4-6 10 21.7% 4 4.7% 14 10.6% >6 1 2.2% 2 2.3% 3 2.3% Number of medical conferences (national and international) attended in the previous year: .13 ≤1 5 10.2% 21 24.1% 26 19.1% 2-3 30 61.2% 47 54.0% 77 56.6% ≥4 14 28.6% 19 21.8% 33 24.3% Number of conference presentations (oral and poster) in the previous year: .012 0 6 13.0% 27 31.0% 33 24.8% 1-4 29 63.0% 54 62.1% 83 62.4% 5-9 8 17.4% 5 5.7% 13 9.8% ≥ 10 3 6.5% 1 1.1% 4 3.0% Medical grants/funding in the previous 5 years: .60 Yes 22 55.0% 48 60.0% 70 38.3% No 18 45.0% 32 40.0% 50 41.7% Frontiers in Oncology 06 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 (18/40) of male vs. 40% (32/80) of female (c2 (1, N = 120) = 0.247, and 39.1% (18/46) assessed that due to the parental leave they have p = .60). missed their career advancements. There was a significant intermediate effect between number of On the question: “If the parental leave affected your academic congress presentations in the previous year and gender. On career?”, there was again a significant difference between male and average, male had more congress presentations (median = 3) female. 44.4% (24/54) female and 5.9% (1/17) man perceived that than female (median = 2). The difference was significant U parental leave had adversely affected their academic career (OR (Nmale = 46, Nfemale = 87) = 2,651.5, z = 3.13, p = .002, h2 = .071. 12.8, 95% CI 1.58-103.53, p = .004, c2 (1, N = 71) = 8.43, moderate On the question: “Are you happy with your current effect size f = .35). 42.5% (17/40) female stated that because of academic achievements?”, 27.3% (15/55) of female and 41.9% parental leave, they did not manage to actively participate in (13/31) of male confirmed their happiness with their current research projects and could not publish, 27.5% (11/40) stated that academic achievements, this association was not statistically they did not get the desired academic position, 12.5% (5/40) stated significant (c2 (1, N = 86) = 1.94, p = .164). that they did not have time to enroll in PhD studies and did not have time to work with students/fellows/residents. A significant higher number of female 41.8% (23/55) than of Challenges for career development and male 14.3% (3/21) were feeling underestimated by their barriers for gender parity manager, because of using parental leave (OR 4.31, 95% CI 1.14-16.4, p = .024, c2 (1, N = 76) = 5.12, small to moderate effect Among female, child planning was extremely important in size f = .26). 31.5% (17/54) of the respondents, considerably important in The significant majority of female, 79.3% (65/82), see 37% (20/54) and not important at all in 13% (7/54), while among obstacles for career success for females in surgical gynecologic male it was extremely important in 7.5% (3/40) of the oncology compared to less than half of male, 46.2% (18/39), (OR respondents, considerably important in 32.5% (13/40) and not 4.46, 95% CI 1.95-10.2, p<.001, c2 (1, N = 121) = 5.12, moderate important at all in 20% (8/40). Planning parenting was playing a effect size f = .33). Figure 2 presents the perceived obstacles for major role in carrier development and there was a moderate career success among female in surgical gynecologic oncology. positive correlation with gender (d = .35, p = .001). On the question: “Do you think that the parental leave has affected your clinical career?”, 48.1% (26/54) of female deemed that Suggested ways for gender parental leave has affected their clinical carrier vs. 20% (4/20) of parity achievement male (OR 3.71, 95% CI 1.11-12.57, p = .029, c2 (1, N = 74) = 4.79, small to moderate effect size f = .26). When asked in which way has The suggested ways to increase the feasibility for a woman to the parental leave affected their clinical career, 45.7% (21/46) of be both a successful gynecologic oncology surgeon and a caring female stated that it was the lack of surgical activities while on leave, mother are presented in Figure 3. FIGURE 2 Perceived obstacles for career success among female in surgical gynecologic oncology. Frontiers in Oncology 07 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 FIGURE 3 Suggested ways to increase the feasibility for a woman to be both a successful gynecologic oncology surgeon and a caring mother. On the question: “According to you could ESGO and Figure 4 presents the answers to the question: “If you were ENYGO help improving the gender disparity in the field of now about to choose your career, what would you do?”. 77.5% gynecologic oncology surgery?” 76.5% (62/81) of female and (31/40) of male and 70.9% (56/79) of female answered that they 55.6% (20/36) of male gave a positive answer. Table 5 presents would stay with their career choice. 10% (4/40) of male and selected individual suggestions on options how ESGO and 19% (15/79) of female stated that they would choose a non- ENYGO could help. medical career. There was not a significant association between TABLE 5 Selected individual suggestions on how ESGO and ENYGO could help improving the gender disparity in gynecologic oncology surgery. • This survey is already helpful and is a good start in promoting female to reach parity and change the perspective of the old generation. • Encourage and support female in their clinical and research fellowships. • Organize hands on courses and courses in leadership especially designed for female. • ESGO and ENYGO should promote female as role models at the conferences. At least 50% female at all of their committees. More female at leadership position in the both of the organizations. Also, at least 50% of conference speakers should be female. • Provide a better network between colleagues from different centers. • Successful female in this field should openly talk on conferences about managing family and work. • Gender disparity issues should be analyzed within ESGO and ENYGO committees. The visuality of this problem should be increased at open forums. Discussions and public awareness initiatives are needed. Promotion of activities to spread awareness of this problem. • Providing training scholarships and grants for female. Giving priority to applicants with children. • Fellowships should be well paid and should be with a shorter duration. More regional meetings should be organized. Mentor-fellow system of training in the host hospitals for better acquisition of specific surgical skills. • Female mentorship programs. Encouraging academic/clinical leads to facilitate and support female. • Providing childcare during conference, financial support for female coming to conferences with children. Providing special time and places at congress for female surgeons with children. • More online educational platforms. • Promoting a culture of understanding of mothers. • Promoting female surgical career and put in value the female’s work in this field. • Support pregnant female in being allowed to still do surgery. Setting up mentoring and fellowship programs, especially for female and encouraging hospitals to invest in the training of their female gynecologic oncology surgeons. • To encourage young woman to do surgery. • Flexible working models. • Day-care organized by the clinical setting. Frontiers in Oncology 08 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 FIGURE 4 If you were now about to choose your career, what would you do? gender and the current career choice c2 (3, N = 119) = 2.1, p 2019/2020 female were 29% of the chairs, 46% of the vice chairs, = .55). and 47% of the division directors (16). Gender disparity in leadership position has been previously reported in the field of medical oncology as well. Banerjee et al. Discussion demonstrated a significant male dominance at leadership positions among respondents mainly practicing in Europe, In this study we report on gender disparities in the critical 71% (11). Furthermore, a recent leadership study in the time of career development among the young generation of United States of America identified the absence of female gynecologic oncology surgeons in Europe based on an gynecologic oncologists at cancer center director positions international survey. To the best of our knowledge this is the (17). Another study in the United States of America exposed first comprehensive evaluation of gender differences and that female constituted only a minority of all faculty in academic experienced obstacles in carrier development among gynecologic oncology institutions (medical oncology, radiation oncology and oncology surgeons. surgical oncology) and the low female representation was Self- reported data in our survey showed a higher exposure particularly pronounced at a leadership level (18). of male compared to female to operative procedures during their In our study the male dominance at leadership positions was fellowships and as young specialists in gynecologic oncology particularly displayed when focusing on leadership at younger surgery (Table 2). The predominance of male over female age (under 41 years) and on younger age plus having children surgeons has been described before and is well known in (Table 3). The adjusted odds ratio for male in a leadership different surgical disciplines, e.g. a Canadian population based position was more than 3 and notably more than 10 times retrospective study has included all surgical disciplines and higher, respectively, compared to female with these attributes in reported that only 12.4% of identified surgeries were life. Parenting and domestic duties mainly carried out by female performed by females (12). together with other factors probably contribute to hampered Although the majority of specialists in gynecology and career advancement and gender disparity seen in leadership obstetrics worldwide are nowadays female, the published positions. Among high-achieving young physician-researchers it literature reports on an underrepresentation of female in was reported that female with children spent a longer time on leadership positions (13, 14). The comparison of two domestic duties and were more dedicated to childcare activities observational studies on leadership positions in gynecology compared to male (19). Furthermore, the impact of gender and and obstetrics performed in the periods 2012/2013 and 2019/ parenthood on physician’s career success was investigated by 2020 in United States of America shows a slight increase in the Buddeberg-Fischer B. at al. who performed a prospective study percentage of female in leadership positions. In the period 2012/ on career development among young physicians in the first 2013 20% of the chairs of departments were female; 36.1% of the seven years after graduation in Switzerland. They found out a vice chairs and 29.6% of the division directors (15). In the period lower career success among female physicians, especially those Frontiers in Oncology 09 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 with children in comparison to their male colleagues. Moreover encourage female colleagues that they can succeed, and to female physicians with children tended to work in smaller support them during the process of their carrier development. hospitals or private practices and aspired less often to senior Among the offered options on how to increase the feasibility hospital leading positions (20). for a woman to be at a same time both a successful gynecologic In our study a significantly higher proportion of female than oncology surgeon AND a caring mother (Figure 3) both genders male believed that they earn less than their gender counterparts at agreed that more flexible working hours and child day-care the same clinical position with comparable clinical and academic organized by the working place could be helpful in this direction. qualifications, with an impressive odds ratio of around 17. This Valuable selected individual suggestions have been received estimate is leveled with data reported by Croft et al. who analyzed on the open question on how ESGO and ENYGO could help to exact annual income sums among gynecologic oncologists in overcome gender disparity in gynecologic oncology surgery USA. They found that 75% of female gynecologic oncologists in (Table 5): children friendly conferences with organized academic settings make bellow the median salary calculated for daycare and space for mothers and children, promotion of the combined group of gynecologic oncologists of both genders female as role models at ESGO and ENYGO conferences, (21). Further reports have robustly pointed out the gender reaching parity at ESGO and ENYGO committees and among reimbursement gap among medical oncologists in Europe and invited conference speakers, open forums with discussion on among health care providers in the USA (11, 22, 23). current gender issues to increase awareness and prompt support With respect to PhD degrees and professorship positions, for female in their clinical and research advancement, leadership our finding in gynecologic oncology surgery are in contradiction academies for female, flexible working-models and day care to data reported in medical oncology by Elez et al. (24), who did organized by the working place. report on a gender gap, while we did not reveal a gender Regardless of the numerous exposed challenges and barriers disparity in our survey. However, our analysis showed that and the significant dissatisfaction in the field of clinical male published more than female. This is in line with previous gynecologic oncology surgery, the majority of female would not gender related publication analyses in the field of gynecologic change and would opt again for gynecologic oncology surgery. oncology (4, 25). Furthermore, our survey revealed that male with children published significantly more than female with children, which might again be related to female taking more Study strengths and limitations responsibility in domestic duties and in childcare. Planning parenting during training was of a higher importance To the best of our knowledge our study is first for female than for male respondents in this survey, which is comprehensive evaluation of the gender-related differences matching with published data among general gynecologists and among gynecologic oncology surgeons in Europe that provides gynecologic oncologists (26, 27). Such difference in perceived an in-depth analysis of several specific problems. Also, the used importance of family planning seems logical in light of gender qualitative methods allow a careful description of the broad specific influence on working opportunities and impact on career spectrum of gender climate. advancement by a decision for a family. Also, an initial career The biggest limitation of the study is that it is based on self- accomplishment and a subsequent child planning is feasible for reported data. Also, there might be a selection bias with respect male, but not for female. Fertility struggles were reported among to those ENYGO members, who decided to fill in the survey. gynecologic oncologists in United States of America with an ENYGO is a diverse network of physicians interested in impressive rate of 81% of females having sought infertility gynecologic oncology as it is the training and certification counseling (26). Indeed, parental leave was mainly utilized by process in gynecologic oncology in various European female and covered a much longer timeframe. It was accompanied countries. This leads to certain limitations in our study. Since with a feeling of being underestimated by their supervisors and by this survey was sent only to ENYGO members, representing the the impression that parental leave has adversely affected their career, younger generations of gynecologic oncology surgeons, our both academically and clinically due to lack of exposure to results give insights to gender issues mainly in the third and surgical procedures. fourth decade of age only. Based on the presented data, a more Both, male and female, recognize that there are obstacles in the focused survey on gender discrepancies is already planned to be career development for female in the field of gynecologic oncology distributed among all ESGO members, which could enable a surgery. The majority of male perceive the “family concerns” as the further more profound analyses. biggest obstacle for female, whereas female related their experienced carrier barriers mainly to gynecologic oncology being a closed “male club” besides the family concerns. Curiously, none of the male Conclusion respondents perceived their subspecialty as a “male club”. This finding underlines the importance of more females in leadership Although female present a rising proportion in the field of positions in gynecologic oncology to serve as role-models, to gynecologic oncology surgery in Europe, male prevail over Frontiers in Oncology 10 frontiersin.org Nikolova et al. 10.3389/fonc.2022.1005130 female as surgeons in operating theaters and dominate at Author contributions leadership positions. Different factors related to family and childcare seem to adversely influence the clinical career TN performed the conception and design of the study. TN, MB, advancement among female, while the effect of family NN, KZ, JK-B, and ZR designed the survey. NN organized the planning and parenting in male seems comparably small. database. TN and NN performed the statistical analysis. TN wrote It is not a lack of attractiveness or deficient wish of female to the draft of the manuscript. All authors contributed to manuscript work in the field of gynecologic oncology surgery that explains revision, read, and approved the submitted version. NC did the the low number of females in leadership positions in this field. senior supervision and last revision of the manuscript. The majority of female would opt again for gynecologic oncology surgery. Obviously, there are obstacles in the critical time of career development that lead to a substantial attrition of female from training to leadership functions in gynecologic oncology. Acknowledgments ESGO and ENYGO aim to work on the implementation of Authors would like to thank all ENYGO members (2019- measures and programs to overcome the identified obstacles, to 2021) and ESGO office for the great support to the present study. close gender gaps, and support female to fully invest their skills, power and indispensable potential in the field of gynecological oncology surgery. Conflict of interest Data availability statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could The raw data supporting the conclusions of this article will be construed as a potential conflict of interest. be made available by the authors, without undue reservation. 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