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339SIUJ.ORG SIUJ  •  Volume 2, Number 6  •  November 2021

GUEST EDITORIAL

The Rising Tide of Women in Urology
Pilar Laguna

Department of Urology, Istanbul Medipol University, Turkey

Soc Int Urol J.2021;2(6):339–343

DOI: 10.48083/JHEK4332

I read with pleasure the editorial “A Global Pandemic 
Is Not Our Only Challenge in Urology” in the January 
2021 issue of SIUJ[1]. Indeed, the pandemic has not only 
challenged us professionally but has also highlighted 
a social unrest and accelerating global claims at all 
societal levels. Not least among these are the calls for 
gender equity and equality in our profession in general, 
and urology in particular.

I believe the genders possess equal intellectual capacity, 
the same ability to acquire professional and surgical skills, 
and the same qualities that lead to a successful career 
(academic or not). The gender differences in the ways of 
approaching and solving a conflict—or even the small 
events of daily life—are, like all diversity, enriching.

Equity, although connected to equality in several 
respects, is more complex in substance and more difficult 
to achieve; once achieved, effort must continue if it is to be 
maintained.

Belonging to the first generation of “women of urol-
ogy” does not grant me any authority, but it does give 
me a wider experience and a log-book full of anecdotes. 
Most laughable, some embarrassing, and a few defi-
nitely unpleasant. The last usually the fruit of the limited 
minds of some male individuals, but a few from females. 
As a matter of fact, I must disclose that the incident I 
remember as the most cruelly discriminative came from 
the mouth of a women—and not so many years ago. 
Taken together, they illustrate how it has been working 
in a male-dominated surgical specialty and how some 
characteristics and attitudes are unfortunately not 
gender exclusive.

In almost 4 decades working as a urologist, I have 
witnessed the increasing number of women incorpo-
rated into the urology workforce. Very slowly at the 
beginning, but steadily and more prominently when 
the Gen X-ers and the first Millennials reached our 
specialty with a refreshing impetus. Like the excellent 
young professional females named in the January edito-
rial, we also won prizes, became chairs of departments, 
were involved in academic work, and did our best to care 
for our patients. There were a handful of us, likely with 

different values and perceptions and with fewer oppor-
tunities to communicate than today’s young profession-
als. We accepted that it would take some time to become 
fully integrated in that “male-dominated” world. None-
theless, paving the way for the next generation of females 
in urology, that is what we did.

Gender disparity is not a new concern in medicine 
or in our specialty. A lot has been written exposing the 
problems and the inequalities, but quite a lot has been 
done and more is on the way to minimize and remediate 
the differences.

The urological community started to become seri-
ously concerned about the subject in the late 1990s. 
Surveys from that time show that although the majority 
of female urologists encouraged other women to enter 
the specialty, ultimately 44% of the potential female 
graduates or trainee candidates were discouraged at 
some point. Most believed that gender discrimination 
had or could have some negative effect on their training 
and practice, that gender played a limiting role in our 
specialty, and that there was a lack of adequate mentor-
ing for females[2,3]. Although the information was scant 
and somewhat subjective, and although neither causality 
nor remediation was explored or proposed, these reports 
were the tip of the iceberg and exposed an underlying 
chronic problem. After these first reports, more infor-
mation surfaced pointing to different forms of employ-
ment and work inequality between female and male 
urologists, ranging from different salaries for the same 
workload, practice setting, or fellowship training, and 
unequal work opportunities, to verbal and other forms 
of harassment and discrimination. Always detrimen-
tal for females—and even more so for those pursuing  
surgical specialties[4–7].

Differences and possible inequity have also been 
described in the academic setting. About a decade ago, 
a PubMed query showed that female residents who grad-
uated as urologists from 2002 to 2009 had fewer publi-
cations than their male counterparts and that they were 
less frequently first authors[8]. The phenomenon is not 
unique to our specialty and although the rate of over-
all female authorship in the highest rated journals has 



improved in the last 15 years, it is still half the rate for 
males in specialties with a more balanced male: female 
ratio than urology, eg, general oncology[9]. Further-
more, despite the same proportion of women as men 
pursuing a fellowship and ultimately choosing an 
academic career, a significantly higher proportion of 
men than women (24.7% versus 2.9%) attained the rank 
of associate professor[8].

Most recent data show that in the academic setting, 
too, professional careers do not turn out as well for 
females as for males. Of the 2926 US academic urol-
ogists who were assistant, associate, or full professors, 
only 11.2% were female, and, on average, it took females 
1.2 years longer than men to advance from assistant to 
associate professor[8]. Only gender (not race or ethnic-
ity) was associated with this disparity[10]. The data 
were in line with previous information on gender-based 
academic inequity in medicine and in surgery after 
correcting for possible confounders (number of years 
since residency completion, graduate degrees, fellowship 
training, and markers of research production)[11,12].

As the cherr y on the sundae, female urologic 
surgeons have been reported as having fewer children, 
higher induction rates, and higher incidence of preg-
nancy complications than women in the general popu-
lation[13]. In common with female surgeons in other 
specialties, they are also likely to delay childbearing, and 
to experience fertility problems and rates of miscarriage 
up to 38%, which is very high and likely attributable to 
the demanding nature of the surgical work[14,15]. Given 
this, it is perhaps surprising that although burnout is a 
major concern in our specialty, it is not more prevalent 
in female urologists[16,17].

Overall, the literature provides an extensive list of 
comparative detrimental differences for the female 
gender in medicine. As female surgeons, we seem to be 
particularly subjected to offences or frustrations that 
go beyond inequality to plain and flagrant inequity and 
discrimination.

Far from ignoring the data, we should strive to analyse 
how the evidence has been gathered. Yes, there is an 
association between the variable “female gender” and 
inequality in urology, but this does not necessarily imply 
causality. In fact, a non-negligible portion of the infor-
mation comes from surveys, some with small sample 
sizes, and it is likely to be influenced by perceptions, 
which change with time and experience.

If we aim—and we do—to be fully acknowledged, 
recognized, and integrated into the “urology task force,” 
and to have access to the higher academic ranks and 
positions of power, the sensitive matter of inequality 
and inequity deserves a more rigorous and objective 
approach. Only with honesty, integrity, reflection, and 

an open and inclusive mind are we going to overcome 
the challenge.

While all this information points in the direction of 
“de facto” environmental inequality and lack of equal 
opportunities for women in urology, much of the exten-
sive body of information does not reflect the current 
picture. Social and working conditions are not the same 
now as they were 30—or even 20—years ago, and it is 
undeniable that women have already become visible in 
urology.

According to the recently released census of the 
American Urological Association (AUA), females 
for the first time surpassed 10% of the urology work-
force[18]. Not a lot, but a milestone in a “male-domi-
nated specialty.” An unprecedent increase of nearly 50% 
in the number of women in urology occurred in the last 
5 years, with the higher proportion of female urologists 
being in the younger age groups[19].

Even more encouraging are the figures just released by 
the European Association of Urology (EAU) indicating 
that 16.6% of their members are women[20]. Although 
not quantified, the major increase of women in urology 
over the last few years in Europe has been more than 
evident. I would even dare to say that the phenomenon 
started earlier here than in North America. At present, 
the number of female urology trainees surpasses 50%, 
and it is even higher in some European countries—far 
more than the 24.4% reported by the AUA[18]. Although 
this may be the result of women having increased access 
to medical university places, we cannot ignore the fact 
that changes in social attitudes about male and female 
roles and structural modifications in the training and 
work environment may have had a definitive influence.

There are indeed differences between female and male 
urologists in patterns of practice, and gender shapes the 
clinical landscape. Women more frequently subspe-
cialize in female urology and work in academic centers 
and in metropolitan areas[21,22]. According to the AUA 
census, women already account for 46.5% in female 
pelvic medicine and reconstructive surgery (FPMRS)
[18,23]. Considering the female prevalence in the AUA 
Task Force report, this is disproportionate[18]. Whether 
the choice is driven by personal preferences or patient 
preferences or is imposed by restrictive access to other 
subspecialties is unknown, but inevitably, it is going to 
skew the prevalence of females in other subspecialties. 
Of note, FPMRS also had the highest proportion of 
members of groups categorized as “underrepresented in 
medicine” (URiM) compared with the other subspecial-
ties[23].

In Canada, a country with high social equality stan-
dards, there are significantly more male than female 
academic urologists. A retrospective study published in 

340 SIUJ  •  Volume 2, Number 6  •  November 2021 SIUJ.ORG

 GUEST EDITORIAL



2020 found that as academic rank increases, the propor-
tion of female urologists decreases, and male urolo-
gists have significantly higher academic ranks, h-index 
values, number of publications, and citations. The lack 
of females in senior academic leadership is not surpris-
ing given that the history of females in urology goes 
back only 50 years[24,25]. The accompanying editorial 
stresses the need to clarify the reported gender discrep-
ancies in academic urology and incorporate different 
measures of academic productivity such as educational 
and continuing medical education (CME) activities. 
Moreover, the authors make a plea for considering abil-
ity, talent, dedication, and innovation above gender[25].

Female urologists are increasingly included in work-
ing groups and panels in international meetings[20] 
with 2021 seeming to be a turning point. The American 
College of Surgeons is planning measures to address 
inequities that affect women in medicine and those 
who are seeking to enter the profession[26]. Major jour-
nals and important health institutions have echoed the 
need for inclusion and diversity and taken measures 
to promote equity and equality at all levels of medi-
cine[27,28].

In 2020, at least 4 prestigious awards were given to 
brilliant female urologists—role models practicing in 
subspecialties beyond the ones conventionally reserved 
for female urologists. So far in 2021, 4 “women of urol-
ogy” have been recognized by the AUA: Catherine R. 
deVries with the Humanitarian Recognition Award of 
the AUA Urology Care Foundation; Tracey L. Krupski 
with the Robert C. Flanigan Education Award; Mary-
Ann Lynn Stothers with the Victor A. Politano Award; 
and Stacy Loeb with the Gold Cystoscope Award. In 
Europe, Véronique Phé, a young female urologist, 
received the prestigious EAU Crystal Matula Award.

Also, the Society of Women in Urology turns 40 this 
year. SIU has had women on its Board for many years, 
and for the last 4 years, the Society’s Scientific Commit-
tee has devoted special attention to inclusivity and diver-
sity. This without forgetting all the “women of urology” 
who have become chairs, professors, and academicians. 
Thus, it seems clear to me that we do not need to be 
indoctrinated in how to become “women in the lead,” 
because we are not doing so badly.

On February 9, 2019, the Lancet dedicated an issue 
to women in medicine that included an enjoyable piece 
entitled “Working toward gender diversity and inclusion 
in medicine: myths and solutions”[29]. It is about the 
major myths that prevent diversity and inclusion and the 
possible solutions beyond individual behavior. It is also 
about the need to see the problem beyond the number 
of women in the field and to create lasting changes 
based on fair and transparent institutional policies, on 
the commitment of all involved parties to change group 
dynamics, on changes in societal values, and on under-
standing that promoting diversity does not contravene 
meritocracy.

I would like to finish by mentioning briefly a disturb-
ing phenomenon that is no doubt familiar to you, 
namely, the “manel,” or panel consisting only of men. 
They are unbalanced and exclusive, but the same applies 
to the “wanels,” which do now exist. Both are toxic and 
equally discriminative. The latter may be even worse 
because of the implicit and troubling tokenism. I hear 
with concern the increasingly raised voices of both males 
and females, expressing dissatisfaction and discomfort. 
The former afraid they will be discriminated against 
in the interests of redressing the balance, and the latter 
afraid they will be invited only because they are women. 
And I do not like it. Although some think that numbers 
are irrelevant when equity is the issue, the truth is that 
we have used them to build up our case, so we should be 
consistent in using them to measure our progress.

In summary, the turmoil regarding disparity and the 
need for diversity and equity—for all underrepresented 
groups—has never been so evident and urgent as it is 
now. The speed of media diffusion and the increasing 
penetration of these groups makes it different from the 
past. It seems to me that we females are navigating quite 
well in the ocean of our specialty, but there is still a lot to 
do. All of us—male and female—must do the work well, 
ensure that we have a solid vessel, remain steadfast at the 
helm, and modify the course to avoid the storms.

Finally, I have nothing but praise and thanks to offer 
the major societies in urology—EAU, AUA, SIU, the 
Endourological Society, and the many others—that have 
never made me feel discriminated against.

341SIUJ.ORG SIUJ  •  Volume 2, Number 6  •  November 2021

The Rising Tide of Women in Urology



References

1. Black P. A global pandemic is not our only challenge in Urology. Soc Int 
Urol J.2021;2:5–6. DOI: https://doi.org/10.48083/GOZD2340

2. Bradbury CL, King DK, Middleton RG. Female urologists: a growing 
population. J Urol.1997;157: 1854–1856.

3. Lightner DJ, Terris MK, Tsao AK, Naughton CK, Lohse CM. Status 
of women in urology: based on a report to the Society of University 
Urologists. J Urol.2005 Feb;173(2):560 – 563. doi: 10.1097/01.
ju.0000149739.51103.d3.

4. Spencer ES, Deal AM, Pruthi NR, Gonzalez CM, Kirby EW, Langston J, 
et al. Gender differences in compensation, job satisfaction and other 
practice patterns in urology. J Urol.2016 Feb;195(2):450–455. doi: 
10.1016/j.juro.2015.08.100. Epub 2015 Sep 15.

5. Schlik CJR, Ellis RJ, Etkin CD, Greenberg CC, Greenberg JA, Turner 
PL, et al. Experiences of gender discrimination and sexual harassment 
among residents in general surgery programs across US. JAMA 
Surg.2021Jul;28:e213195. doi: 10.1001/jamasurg.2021.3195. Online 
ahead of print.

6. Myers SP, Dasari M, Brown JB. Ef fects of gender bias and 
stereotypes in surgical training: a randomized clinical trial. JAMA 
Surg.2020;155(7):552–560.

7. Dossa F, Simpson AN, Sutradhar R, Urbach DR, Tomlinson G, Detsky 
AS, et al. Sex-based disparities in the hourly earnings of surgeons in 
the fee-for-service system in Ontario, Canada. JAMA Surg.2019 Dec 
1;154(12):1134–1142. doi: 10.1001/jamasurg.2019.3769.

8. Yang G, Villalta JD, Weiss DA, Caroll PR, Breyer BN. Gender differences 
in academic productivity and academic career choice among urology 
residents. J Urol.2012;188:1286–1290.

9. Yalamanchali A, Zhang ES, Jagsi R. Trends in female authorship 
in major journals of 3 oncology disciplines. JAMA Network 
Open.2021;4(4):e212252.

10. Breyer BN, Butler C, Fang R, Meeks W, Porten SP, North AC, et al. 
Promotion disparities in academic urology. Urology.2020 Apr;138:16–
23. doi: 10.1016/j.urology.2019.10.042. Epub 2020 Jan 7.

11. Gawad N, Tran A, Martel AB, Baxter NN, Allen M, Manhas N, et al. 
Gender and academic promotion of Canadian general surgeons: a 
cross-sectional study. CMAJ Open.2020 Jan 28;8(1):E34–E40. doi: 
10.9778/cmajo.20190090. Print Jan-Mar 2020.

12. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex 
differences in academic rank in US medical schools in 2014. JAMA. 
2015Sep;15;314(11):1149–1158. doi: 10.1001/jama.2015.10680.

13. Lerner LB, Baltrushes RJ, Stolzmann KL, Garshick E. Satisfaction 
of women urologists with maternity leave and childbirth timing.  
J Urol.2010 Jan;183(1):282–286. doi: 10.1016/j.juro.2009.08.113.

14. Phillips EA, Nimeh T, Braga J, Lerner LB. Does a surgical career affect a 
woman’s childbearing and fertility? A report on pregnancy and fertility 
trends among female surgeons. J Am Coll Surg.2014;219:944–950.

15. Poon S, Luong M, Hargett D, Lorimer S, Nguyen C, Payares M, Friedman 
S. Does a career in orthopaedic surgery affect a woman’s fertility? 
Orthop Surg.2021;29(5):e243–e250. doi: 10.5435/JAAOS-D-20-00198.

16. Ilin J, Langlois E, Jalal S, Khosa F. Gender disparity within academic 
Canadian urology. Can Urol Assoc J.2020;14:106–110.

17. Cox A, Siemens DR. Continued gender disparity in urology? Only time 
will tell. Can Urol Assoc J.2020;14(4):79–80. doi: 10.5489/cuaj.6519. 
Epub 2020 Apr 1.

18. American Urological Association (AUA) 2020 Annual Census Report, 
“The state of the urology workforce and practice in the United States. 
American Urological Association, 2020. Available at: https://www.
auanet.org/research/research-resources/aua-census/census-results. 
Accessed September 25, 2021.

19. Female urologists make history in urology. News release. American 
Urological Association. May 27, 2021. Available at: http://auanet.
mediaroom.com/2021–05–27-Female-Urologists-Make-History-in-
Urology#.YK-qH1V3eEw.twitter. Accessed September 25, 2021.

20. Chapple CR, Albers P, Denstedt J. Addressing equality of representation 
in urology societies. Eur Urol.2021 Oct;80(4):454–455. https://doi.
org/10.1016/j.eururo.2021.07.001

21. Saltzman A, Hebert K, Richman A, Prats S, Togami J, Rickey L, et al. 
Women urologists: changing trends in the workforce. Urology.2016 
May;91:1–5. doi: 10.1016/j.urology.2016.01.035. Epub 2016 Mar 4.

22. Oberlin DT, Vo AX, Bachrach L, Flury SC. The gender divide:.the impact 
of surgeon gender on surgical practice patterns in urology. J Urol.2016 
Nov;196(5):1522–1526.doi: 10.1016/j.juro.2016.05.030. Epub 2016 
May 10.

342 SIUJ  •  Volume 2, Number 6  •  November 2021 SIUJ.ORG

 GUEST EDITORIAL



23. Dielubanza EJ, Enemchukwu EA, Atiemo HO. Urology workforce 
diversity in female pelvic medicine and reconstructive surgery: 
an analysis of the American Urological Association census data. 
Urology.2021 Jul 15;S0090 – 4295(21)00641– 5. doi: 10.1016/j.
urology.2021.06.031. Epub ahead of print.

24. Franc-Guimond J, McNeil B, Schlossberg SM, North AC, Sener A. 
Urologist burnout: frequency, causes and potential solutions to an 
unspoken entity. Can Urol Assoc J.2018;12:137–142. Published online 
2017 Dec 22. doi: 10.5489/cuaj.4668

25. Marchalik D, Goldman CC, Carvalho FFL, Talso M, Lynch JH, Francesco 
Esperto F, et al. Resident burnout in USA and Europe urology residents: 
an international concern. BJU Int.2019 Aug;124(2):349–356. doi: 
10.1111/bju.14774. Epub 2019 May 8.

26. Stephens EH, Heisler CA, Temkin SM, Miller P. The current status 
of women in surger y: how to af fect the future. JAMA Surg. 
2020;155:876–885.

27. Fontanarosa PB, Flanagin A, Ayanian JZ, Bonow RO, Bressler NM, 
Christakis D, et al. Equity and the JAMA Network. JAMA Surg.2021 
Aug 1;156(8):705–707. doi: 10.1001/jamasurg.2021.3098.

28. The Editors of the Lancet Group. The Lancet Group’s commitments to 
gender equity and diversity. Lancet.2019 Aug 10;394(10197):452–453. 
doi: 10.1016/S0140–6736(19)31797–0. Epub 2019 Aug 8.

29. Kang SK, Kaplan S. Working toward gender diversity and inclusion in 
medicine: myths and solutions. Lancet.2019 Feb 9;393(10171):579–
586.doi: 10.1016/S0140–6736(18)33138–6

     

343SIUJ.ORG SIUJ  •  Volume 2, Number 6  •  November 2021

The Rising Tide of Women in Urology


