Women In Neurosurgery: A Critical Assessment of The State of The Specialty in Turkey

BACKGROUND: Although at least half of medical students are women, neurosurgery is not often preferred by women, and the proportion of female neurosurgeons who can participate in the academic platform is very low. OBJECTIVE: In this study, we aimed to show the role of female neurosurgeons in the Turkish Neurosurgical Society. METHODS: We examined the age, academic rank, years of work in the profession, membership rate in society subgroups, h-index parameters, and relationships of certicated female neurosurgeons registered in the Turkish Neurosurgical Society. We examined gender rate differences between society subgroups using chi-square tests. A P value < 0.05 was considered statistically signicant. RESULTS: There are currently 94 board-certied female neurosurgeons between the ages of 31 and 92 years; 10 are full professors (10.6%), 16 are associate professors (17 %), 5 are assistant professors (5.3 %), and 63 are neurosurgery specialist physicians (67 %). Female neurosurgeons are present among six of the subelds categorized by the Turkish Neurosurgical Society: 7 in pediatric neurosurgery (11.47%); 8 in spinal and peripheral nerve surgery (2.4%); 3 in neurovascular surgery (2.02%); 7 in functional neurosurgery (5.8%); 11 in neuroanatomy (9.2%); and 23 in neurooncology (6.9%). CONCLUSIONS: The number of female neurosurgeons in Turkey continues to grow each year. To increase the proportion of women in this eld, it is important to support female neurosurgeons and enable them to take on more tasks.


Introduction
In the past, a minority of physicians in the eld of neurosurgery were women. Moreover, the history of women in working life is one of very slow and small progress, not only in medicine but also throughout the entire workforce.
Today, women comprise more than half of medical school students. In contrast, only 17.5% of medical school students choose neurosurgery residency, and only 5.9% of practicing neurosurgeons are women, despite the predominance of female medical students. [1] According to published studies, the reasons that women are less likely to choose to enter to neurosurgery eld include family life, social obligations due to other work, and women perceive it would be hard to balance having children while having a career as a neurosurgeon. [17] Based on the information available in the literature, regrettably, there is a striking worldwide disproportion between men and women in neurosurgery. [14] Based on data from the World Federation of Neurosurgeons database, only 29% of committee positions are held by female neurosurgeons. [13] Unfortunately, this situation is also currently valid in Turkey. As women become involved in academic neurosurgery and rise to leadership positions, they will serve as role models for female doctors who want to choose neurosurgery.In this article, we present the rst data in the literature to analyze and report the career paths of female neurosurgeons in Turkey. Our aim is to describe the number and the place of female neurosurgeons in Turkey.

Materials And Methods
We obtained the number and names of certi ceted female neurosurgeons from 1985 to 2021 from the Turkish Neurosurgeon Society.
Our parameters included the age, academic rank, years of working in the profession, membership rate in society subgroups, and h-index of female neurosurgeons. To determine all factors, we used the Turkish Neurosurgeon Society database and social media accounts, such as Researchgate, Publons, Google Semantic, and Google Scholar.

Statistical Analyses
Data were collected in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) and analyzed using SPSS version 22.0 (IBM Corporation, Armonk, NY, USA). Gender rate differences between society subgroups were examined using chi-square tests. A P value < 0.05 was considered statistically signi cant.

Results
According to the year-end 2020 data of the Turkish Neurosurgery Society, 94 (5.5%) of the 1,699 neurosurgery specialists registered in Turkey are women. There are currently 94 board-certi ed female neurosurgeons between the ages of 31 and 92 years; 10 are full professors (10.6%), 16 are associate professors (17 %), 5 are assistant professors (5.3 %), and 63 are neurosurgery specialist physicians (67%) ( Table 1). Between 1960 and 1980, there were 4 specialists among those who were professionally doctors of neurosurgery, whereas between 1981 and 2000, there were 9 full professors, 6 associate professors, 1 assistant professor, and 28 specialists (Table 1). Between 2001 and 2021, there were 1 full professors 10 doctors as associate professors, 4 doctors as assistant professors, and 31 doctors as specialists (Table   1). There are currently 9 academics doctors with an h-index greater than 10 (9.5%).

Discussion
There has been a marked increase in the number of women graduating from medical schools. As a result, the number of female neurosurgeons has increased relatively in the 21st century. [11] However, despite this numerical increase, the number of female neurosurgeons is still disproportionately low, as supported by other studies conducted in the literature. [1,4] In the 15th century, Serefeddin Sabuncuoğlu (1385-1470) was the author of the rst illustrated Turkish surgical textbook in the Turkish literature. [3] His book Cerrahiyyetu'l-Haniyye (Imperial Surgery) contains the rst illustrations depicting female surgeons. According to the data obtained in our study, the number of female neurosurgeons still lags behind the desired number in neurosurgery, with a rate of 5.5% (94/1699). However, especially recently, the number of female doctors in neurosurgery has started to increase. This can be explained by the fact that the female doctors in the platform support each other and that the new doctors look to them as an example.
The number of female neurosurgeons pursuing academic careers or holding executive positions is almost nonexistent worldwide. [5] This situation is referred to as the "glass ceiling," a metaphor used to indicate (Figure 3).
[18]The number of female neurosurgeons can be increased through organization and assistance. The joint work of mentor female neurosurgeons and young female neurosurgeons will help to ensure endurance and continuity within the profession. Looking at the literature, it is possible to see results that support the preference of the female-to-female work ratio. Among the journals articles examined by Aslan et al, it was found that 518 of 3247 (16.0%) female neurosurgeons were the rst named author and 352 of 3247 (10.8%) female neurosurgeons were the senior author; accordingly, young doctors in particular preferred to work with female neurosurgeons as mentors. [2] They indicated that the reason for this was that female neurosurgeons sympathized with their struggles and could relate to their di culties. [2] As a result of their research on a large data set of 68,737 published articles in 16 journals, Taha et al also reported an increase in the number of rst and senior-level authors in female neurosurgery over the past years. They also concluded that articles with a female senior author were more likely to have a female rst author as well. [7] Especially with the increased awareness in recent years, initiatives such as the Women's Association of Neurosurgery mentoring program will provide a signi cant contribution to the advancement of young women neurosurgeons in their academic careers. [10] The number of female neurosurgeons continues to increase each year in Turkey, as well as worldwide.
However, despite this increase, it is not yet at su cient levels.
In Turkey, the doors opened in 1959 with Aysima Altınok, and the eld continues to grow every day with an increasing number for female neurosurgeons.

Conclusion
In this study, we reported on women's progress in neurosurgery today as well as the growing future role for women in this speciality in Turkey. The number of female neurosurgeons has especially grown more than ever in the last 20 years.
We believe that this progress in our country will continue to increase in the coming years and that the number of female neurosurgeons will increase even more.

Declarations
Funding This research did not receive any speci c grant from funding agencies in the public, commercial, or notfor-pro t sectors

Con ict of interest
The authors declare that they have no con ict of interest.

Availability of data and material
We have obtained permission from the female neurosurgeons mentioned to use all materials for this article, and we have obtained the necessary permissions from the relevant people within the photographs used.  Tables   Tables 1-4 are not available with this version. Figure 1 A illustration of a Tabibe miniature showing the removal of a dead fetus due to fetal hydrocephalus.

Figure 2
Photograph of Aysima ALTINOK. Published with permission.

Figure 3
An illustration describing the glass ceiling syndrome.