Gender and leadership equity in neurosurgery: a systematic review of representation and authorship trends (2000-2025)

Neurosurgery remains one of the least gender-diverse surgical specialties. We quantified gender representation across the neurosurgical pipeline and assessed authorship and mentorship patterns.

PRISMA-compliant systematic review (2000-2025) of databases and neurosurgical society sources. Random-effects models were used to pool proportions; meta-regression estimated temporal trends; mentorship effect was analyzed as odds ratio for female first authorship when the senior author was female.

Thirty-eight studies (27 workforce/leadership; 11 authorship/editorial) from 75 countries (>40,000 neurosurgeons) were included. Female residents: 20.2% (95% CI 18.0-22.5); female consultants: 18.9% (95% CI 16.1-21.8); female department chairs: 4.5% (95% CI 3.2-5.9). Female first authors: 16.9%; female senior authors: 8.9%; female-female pairs: 2.1%. Female senior authorship more than doubled the odds of a female first author (pooled OR 2.43; 95% CI 1.86-3.17). Thirty-eight studies from 75 countries were included, representing >40,000 neurosurgeons. Women accounted for 20.2% (95% CI 18.0-22.5) of trainees, 18.9% (95% CI 16.1-21.8) of practicing neurosurgeons, and 4.5% (95% CI 3.2-5.9) of department leaders. Female first authorship was 16.9% and senior authorship 8.9%. Female senior authors more than doubled the odds of female first authorship (OR 2.43; 95% CI 1.86-3.17).

Entry into neurosurgery has improved for women, but leadership and senior authorship remain disproportionately male. Increasing the number of women in senior roles is likely to have a multiplicative effect on authorship and visibility.