Raising Up Gender Equity Voices: Report from an International Virtual Assembly in Global Surgery

Background: The adaptation of conferences to virtual platforms has allowed more international colleagues and underrepresented members of the surgical workforce to access educational opportunities. With the purpose of addressing the gap in open-access gender equity education, the Gender Equity Initiative in Global Surgery (GEIGS) held its rst general assembly in 2020 as a pathway to promote capacity building on this topic. Objectives: This article aims to report the organization and outcomes of the GEIGS general assembly as an example of opportunities to develop capacity on gender equity and diversity in global surgery using virtual platforms. Project Design and Implementation: was The project was by an composed of 11 of backgrounds, who were into and The assembly planning was facilitated through weekly meetings under the supervision of the GEIGS steering committee. Main Achievements: a that encompassed and and about intersectionality; enhancing both

Project Design and Implementation: The GEIGS General Assembly was a two-day event held on December 12th and December 20th, 2020. The project was led by an organizing committee, composed of 11 individuals of diverse backgrounds, who were divided into logistics, advocacy, and sessions teams. The assembly planning was facilitated through weekly meetings under the supervision of the GEIGS steering committee.
Main Achievements: GEIGS piloted a virtual global-scale general assembly that encompassed smallgroup and international community building, interactive learning, and advocacy. In terms of regional representation, there were 199 attendees from 46 different countries. The event highlighted the need to promote inclusion of non-English speakers in the global surgery community, and sessions about intersectionality; equity, social justice, and diversity; and national surgical, obstetric, and anesthesia planning garnered the most participant engagement. Moreover, social media engagement mirrored an increased utilization of online platforms for educational, advocacy and promotional purposes, enhancing both scholarly dissemination and capacity building.
Policy Implications: Engaging in global surgery demands identifying leaders who will build awareness, workforce diversity, and capacity. Our report demonstrates that the topic of gender equity has not held a prominent place in global surgery, and that this rst intersectional conference was an initial step to align both agendas and debate the role of female and non-binary health workers in surgical, anesthesia and obstetric specialties in an international, socially engaging, and region-speci c context.

Background
Global surgery is an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who need surgical, obstetric, and anesthesia (SOA) care [1]. Through a collaborative and interprofessional approach, the movement towards global surgery enables economic growth, universal health coverage, and the achievement of the United Nations' Sustainable Development Goals (SDGs), including the SDG5 to "achieve gender equality and empower all women and girls" [2][3][4]. Access to safe and timely surgical care is crucial to promote sexual and reproductive health and rights, a core component of gender equality, as it involves maternal and newborn health, non-communicable diseases and perioperative health, comprehensive abortion care, and sterilization [3].
Even though the "global" adjective promotes a spirit of collaboration, the colonial background and long history of gender inequity still in uences global health dynamics [5]. This is evident by the imbalanced gender and geographic distribution of leadership. A recent report illustrated that only 17% of global health leaders come from low-and middle-income countries (LMICs), with women representing 5% of this amount [6]. Such a pattern extends to global surgery, where women and non-binary gendered people are underrepresented in SOA specialties [3]. These divergences are also seen in distribution of resources and research since 78.5% of SDG5-related publications are from high-income countries (HICs) whereas lowincome countries account for only 1.4% [7]. As a result, important perspectives from these countries are rarely heard.
In order to inform the surgical community and the public on gender disparities in SOA elds, the Gender Equity Initiative in Global Surgery (GEIGS) was founded in 2019, based on three pillars: research, mentorship, and advocacy [8]. Given the paucity of open-access learning opportunities on gender equity for trainees in medicine, GEIGS and similar organizations show potential for providing such instructional spaces. In light of the coronavirus disease 2019 (COVID-19) pandemic, the adaptation of conferences to virtual platforms has allowed more international colleagues and underrepresented members of the surgical workforce to access educational opportunities [9]. With the purpose of addressing the gap in open-access gender equity education, GEIGS held its rst general assembly in 2020 as a pathway to promote capacity-building for its members. To the best of our knowledge, this is the rst international assembly regarding this topic, emphasizing the potential and need for virtual and open-access platforms to effectively communicate gender equity principles in global surgery.

OBJECTIVES
This article aims to report the organization and outcomes of the GEIGS general assembly as an opportunity to develop capacity on gender equity and diversity in global surgery.

Project Design And Implementation
The GEIGS General Assembly was a two-day event held on December 12th and December 20th, 2020, having six hours of scheduled sessions per day (Table 1 and Table 2). The agenda was centered on capacity building activities related to gender equity and global surgery, and sessions to provide members deeper insight into the organization. To achieve these outputs, the event was carried out by an organizing committee (OC) which was selected by an open call for volunteers to all GEIGS members, in October 2020. The OC was composed of 11 individuals, eight of which were female, from nine different countries, including six LMICs. This intersection of diverse perspectives was a crucial component to planning a general assembly focused on capacity building in a truly global context.  Table 2 showing the agenda for day 2 of the GEIGS general assembly. The OC had weekly meetings with GEIGS steering committee members, who would supervise the group's progress, and make collective decisions. To optimize the group's activities, the OC was divided into three teams: logistics, advocacy, and sessions teams. The logistics team was held responsible for outlining the assembly's schedule, coordinating participants' registrations, intermediating the communication between the OC and attendees, and managing the broadcasting platforms. The advocacy team was in charge of elaborating promotional materials for the general assembly and advertising the event on the organization's social media. Finally, the sessions team was accountable for planning the assembly's sessions, in which they could be the facilitators or invite external speakers. All session coordinators had to de ne the session's aims and methods as well as develop its related materials. Besides having the steering committee to advise, GEIGS international team was invited to collaborate with the event planning, especially on session coordination.

Name of Session
Registrations were open on November 30th and closed on December 20th as the event was split into two weekends. Such a decision enabled the OC to set an orderly promotional strategy on social media, which could attract more participants to the assembly, and increase engagement among the global surgery community. Besides, the OC found this period opportune to host debrie ng sessions, in which the group could make arrangements to improve the event's overall performance on the second day.

Main Achievements Regional Perspectives and International Representation
In addition to open general sessions, the assembly featured six region-speci c networking and community building sessions, adopting the World Health Organization regional model. To address regionspeci c needs and issues in these sessions, OC members who had rst-hand understanding of the sociopolitical and cultural contexts of medical students and trainees in that region were appointed as session moderators to facilitate open discussions and build a sense of community. After the event, participants noted that the regional sessions motivated them to take an active role in future local GEIGS initiatives. Each regional session focused on a unique set of topics and challenges related to gender equity. Examples included prevailing societal notions of SOA medical specialties being "better suited" for cisgender men, homophobia and transphobia in the local healthcare workplace, and the overestimation of gender equity progress in countries that have adopted the issue into their national agenda.
Despite the expected differences, overarching themes also emerged. One unifying topic discussed by different regions was the silencing of non-English-speaking experts from academic conferences. Echoing the oppressive colonially rooted history of global health, many international scienti c and medical conferences today continue to favor English-pro cient experts for keynote speeches and other prominent speaking roles. At the same time, the availability of translating services for attendees is often lacking due to the additional costs, logistical di culty, or lack of planning. The gravity of how much valuable learning is lost from these practices was deeply understood following the session on gender inclusivity on Day 1, which featured speaker and transgender activist Ms. Sophie Nouveau, a member of the State LGBT Health Technical Committee of Rio Grande do Sul in Brazil. This session was able to take place because of the interconnected, international network of the OC, and GEIGS, which made a Portuguese-English translator easily available. Not surprisingly, the session was very well-received by participants and frequently mentioned in region-speci c debrief sessions. The session highlighted that English is not the only language spoken by experts, and conversely, not all experts in the eld speak English. Removing linguistic barriers in academic spheres increases access to unique perspectives, which are otherwise missed when the discourse only takes place in English.
Global Outreach, Social Media, and Capacity Building The focus of this general assembly was capacity building for an international network of activists for gender equity in SOA specialties. Challenged by the current need for social distancing and dangers of travel, GEIGS piloted a virtual approach for hosting its rst global-scale general assembly that would still encompass small-group community building, interactive learning, and concurrent sessions. In total, there were 199 attendees from 46 different countries; a world map depicting these countries and levels of attendance by country is shown in Figure 1. Strati cation of participants using the World Bank income categories shows that: 43 (21.6%) were from HICs, 80 (40.7%) from upper-middle income countries, 54 (27.6%) from lower-middle income countries, and 19 (9.5%) from low-income countries.
Of note, the recruitment window between the launch of the rst promotional materials on social media and the rst day of the event was only 11 days, demonstrating the wide outreach of and interest in the topic of gender equity in global surgery. Social media platforms, such as Twitter and Facebook, have long been a popular medium for more equitable information sharing, and play a prominent role in the global surgery movement. The recruitment success of the social media campaign in such a short time frame mirrors what other organizations, societies, and studies have seen regarding an increase in the interest for and utilization of online platforms during the COVID-19 pandemic.
The vast engagement on GEIGS social media during and immediately following the general assembly highlights a key point to bene t events even in the post-pandemic era. The GEIGS general assembly had 34 tweets but as many as 27,141 Twitter impressions for the days that the event took place. GEIGS twitter impressions and engagement counts over a 60-day span that encompasses the general assembly, as well as the days preceding and following the event, are depicted in Figure 2. On Facebook, GEIGS saw a 394% increase in video engagement and a net 8% increase in followers following the livestreaming of the general assembly events on our initiative page. With its opportunity for instantaneous global connectivity and discussions, social media platforms can have an important role complementary to conferences in terms of enhancing both scholarly dissemination and capacity building.

Learner Interest and Knowledge Gaps in SOA Gender Inclusivity Education
The social media engagement on the general assembly sessions highlighted attendee interest in diversity, equity, and intersectionality, traditionally de ned as the investigational framework of inequities exacerbated at the intersection of gender and race [10]. Particularly, the "Intersectionality in Global Surgery" and the "The Value of Equity, Social Justice and Diversity in Surgical Education'' sessions garnered the most attention and engagement. The aims of these sessions were to expand gender equity in SOA elds beyond the cisnormalized gender binary view and to highlight the additional inequities at intersection with these social identities, particularly regarding racism. These are topics for which academic SOA resources and discussions are severely lacking.
Another session that proved to be challenging for the OC to organize, mainly due to the paucity of existing educational resources, was the session focusing on Gender Equity and National Surgical, Obstetric, and Anesthesia Plans (NSOAPs). Despite NSOAPs being a central theme in global surgery, to the authors' knowledge, there are no existing or openly available lectures, lesson plans, or academic presentations focusing on the integration of gender equity and NSOAPs. This nding is striking given that gender equality is listed as one of the fundamental SDGs.

Policy Implications
Here we reported the organization of the rst conference centered on gender equity in global surgery, focusing on aspects such as international collaboration, capacity-building, social media outreach, and some of our most appreciated sessions. Engaging in global surgery demands management of actor power, meaning that it should promote visibility to the eld and attract stakeholders. Consequently, identifying leaders who will build awareness and gather political in uence is a vital step [10]. Activities like the general assembly lay the basis to raise capacity in global surgery and seek gender equity.
The colonial roots still prevail in the current global health landscape, with marked power asymmetries between the global South and North. The pattern extends to the skewed global health leadership, dominated by the HICs, men, and English speakers [6]. In these circumstances, ensuring a diverse speakers' list as well as the proposal of holding region-speci c sessions was of utmost importance to the general assembly for several reasons. It demonstrates respect not only to nonconventional epistemologies but also to those often excluded from knowledge production.
Moreover, the assembly proportioned an adequate space to debate the role of female and non-binary health workers in SOA specialties. Although women make up an estimated 70% of the global healthcare workforce, they are underrepresented in multiple distinct elds [11,12]. The gender variable has been associated with adverse implications while choosing the surgical eld, training for residency programs, and daily working in medical practice [13][14][15]. When appraising the intersections with minorities based on race, sexuality, and socioeconomic class, the gap expands [14,16,17]. In this sense, GEIGS general assembly had capacity-building as a core value for its members and external participants. By spotlighting meaningful conversations on equity, the event nurtured the empowerment of women and non-binary groups.
A relevant aspect of this general assembly was bringing awareness to considering gender in decisionmaking processes. This feature was pervasive in sessions related to NSOAPs, intersectionality, and social justice. For example, existing supportive bene ts, like parental leave, and mechanisms to report discrimination play a vital role in retaining these groups in the SOA elds [15]. Along with these strategies, promoting diversity and putting women and non-binary people in leadership helps to mitigate the pipeline effect [16,18]. The "leaky pipeline" effect describes a precipitous decline in women compared with men at each progressive step in the academic ladder, in which women occupy less leadership roles such as faculty, division chiefs, full professors, department chairs, and deans [18,19]. This general assembly brought to light that open-access virtual discussions can provide valuable platforms for learning about, engaging in, and planning future advocacy related to policy and program development.
Another point to stress was the relevance of social media as an advocacy tool. Although sometimes underestimated, social media exerts a signi cant contribution to social change [20][21][22], with a prominent role in the global surgery movement. From forwarding public health education to countering misinformation, social media may accelerate research and information dissemination [22,23]. In our project, social media contributed to the successful organization of the general assembly along with disseminating knowledge about gender equity and global surgery to our members and beyond. Additionally, GEIGS social media supported the creation of networks throughout the event, which is bene cial not only for growing the gender equity movement but also to raise and engage new advocates in global surgery decision and policy-making processes [24].
As for the strength of our project, it is possible to highlight the possibility of hosting a conference with no cost to attendees and streaming across multiple social media platforms. Moreover, the event was led by a diverse OC and counted with an inclusive group of speakers, ranging from recognized global surgery leaders to non-English and non-cisgender speakers in alignment with the assembly's proposal. Nevertheless, this project had some limitations. Firstly, choosing an occidental time zone to host the event may have resulted in a low-participation rate from certain regions as South-East Asian and Western Paci c, shaping our audience's pro le. Secondly, it is likely that the short interval between the conference's announcement and occurrence in uenced the number of participants that attended the event, and more preparation on this matter is required for future editions.
The GEIGS general assembly provided a novel framework that enabled attendees from geographic regions and genders otherwise underrepresented in global surgery and global health to discuss actions for achieving gender equity within global surgery. Due to the limitations of the COVID-19 pandemic, the event was organized using virtual conferencing and social media platforms. However, this proved to be the ideal approach for capacity building in an international and region-speci c context, owing to its instant, and participatory nature. Our report demonstrates that gender equity has not held a prominent place in global surgery, and that this rst conference on the intersection of the two topics was an initial step in aligning their agendas. Hence, our assembly can be used as a learning tool for other student-led global surgery bodies to organize upcoming conferences of this character and magnitude.

Declarations
Ethics approval and consent to participate: All data collected from the participants was consented through the general assembly's registration form, in accordance with the European Data Protection Law GDPR. All registrants' information was anonymized for storage, and if they were free to request removal of their data in GEIGS storage. In addition, all presented data is aggregated in a manner to protect any possible identi cations from participants. Consent for publication: Not applicable.
Availability of data and materials: All data generated or analysed during this study are included in this published article.
Competing interests: The authors declare that they have no known competing nancial interests or personal relationships that could have appeared to in uence the work reported in this paper.