The gender gap within urology continues to be one of the largest in medicine, with women making up only 10% of practicing physicians and 16% of academic urologists.¹ This gap widens further when examining leadership positions, where women hold only 3% of department/division chair positions and 8% of program director positions.² Despite this continued underrepresentation, significant increases in the proportion of woman trainees in the specialty have occurred over the last several decades, with women now making up 27% of urology residents and 30% of residency applicants.³ In order for this trend to continue, a greater effort to attract, recruit and retain women in our specialty is necessary, beginning at the trainee level. Therefore, increased awareness of gender-based disparities and bias within the application process is paramount.

Match rates between men and women applying into urology are similar, and the overwhelming majority of the urological residency application is comparable between genders, with slight differences in applicant demographics and metrics. A study of over 500 students applying in 2 consecutive years to Columbia University found that woman medical students had more honors (3 vs 2, p=0.02), while men had marginally higher United States Medical Licensing Examination step 1 scores (238 vs 234, p <0.001) and increased number of published manuscripts (2 vs 1, p=0.02).³ Not surprisingly, the notable gender-based differences between applications are not objective measures such as accolades and test scores, but rather the way in which students are described by both others and themselves, a mark of bias in and of itself. Examples of descriptive application components containing known gender-based differences include linguistic differences within letters of recommendation and personal statements, the residency interview experience and career expectations.

Linguistic analysis of 460 letters of recommendation (LORs) for applicants to a single urology residency program showed that letter writers described male applicants with more characteristics typically desirable in a surgeon (power, drive, work) when compared to women. Of note, a description of power within an LOR was significantly associated with a successful match outcome.⁴

Similar linguistic analysis of applicant personal statements showed that women wrote their statements with decreased confidence and sense of belonging as compared to their male peers, possibly a reflection of woman applicants’ internalization of underrepresentation within urology. Women also self-promoted in their personal statements in a different way than men, using more social and relationship-oriented language that was less assertive and less self-oriented than their male counterparts.⁵ While adherent to gender norms that prevent women from appearing immodest, this may lead to woman applicants “selling themselves short.”

In addition to letters of reference and personal statements, gender differences exist within the residency interview experience itself. Woman applicants are more likely to experience illegal interview questions that do not directly relate to an applicants’ performance ability, specifically regarding family planning, pregnancy and relationship status. Women are also more likely to change their rank list in accordance with inappropriate interview questions.⁶

Finally, differences between female and male urology residency applicants extends to applicants’ career expectations. All applicants, regardless of gender, share similar interests in pursuing fellowship. However, men show more interest in academics, oncology and endourology, while women show more interest in female pelvic medicine and reconstructive surgery, andrology and sexual medicine, and pediatric urology. Despite these early interests, women are more likely to pursue fellowships and academic positions as subspecialists than men (34.4% vs 24.3%).² Reasons for this may include increased flexibility of academic jobs, more clear pathways for mentorship or lack of confidence that improves with additional training.⁷

Ameliorating bias within the urology residency application process requires both an understanding of existing gender biases and barriers but also an awareness of ways in which these biases can be identified and addressed. Standardized LORs have been suggested to avoid implicit gender-based biases.⁸ In addition, online resources provide suggestions to avoid gender bias when writing LORs, such as emphasizing accomplishments over efforts and avoiding stereotypically female-associated words such as “caring” and “warm.”⁴ Bias training should be encouraged for all applicant reviewers as well as applicants themselves. Ultimately, blinding applicant reviewers to gender, race and pictures during initial application review may more reliably remove potential biases when determining interview offers. Programs should ensure that all interviewers are educated in inappropriate and inadvisable questions and topics in order to avoid ranking decisions based on discrimination.

Although the proportion of women in urology is growing steadily, woman trainees now make up over 50% of medical student enrollees. Thus, continued underrepresentation of women in urology likely reflects a lack of focused recruitment and mentorship of woman medical students. In a study of 2015–2019 AUA Match applicants, a strong positive correlation was noted between woman urology applicants and the proportion of woman urological faculty at their home program.⁹ Likewise, woman medical students and residents identified the presence of a woman faculty member as the most important factor when seeking mentorship.¹⁰ Increasing exposure and networking opportunities to female students early within medical education can be achieved through research or summer programs as well as urology interest groups. Programs should focus on active recruitment of female faculty candidates, implementation of professional development programs and alternative promotion programs to retain women in academic urology who can serve as role models and mentors. Focused female mentorship programs that can provide mentorship pairing along with review of personal statements, such as programs promoted by the Society of Women in Urology, should be supported. Furthermore, the regular practice of sponsorship should be championed for women within urology, providing support through advocacy, promotion and connections.¹¹ Combining the sponsorship and mentorship of women with the active process of addressing bias among letter writers, reviewers and interviewers makes closing the gender gap within urology an achievable reality.