“You can’t advance in urology these days unless you’re a woman, minority, or LGBT.”

Have you heard similar sentiments in your professional setting? Well, the authors have. We believe that this sentiment is a myth representing the fear of lost opportunities for some of our colleagues. As recent efforts to improve demographic disparities and underrepresentation in the urological workforce come to bear, a subtle backlash has arisen. For some, questions remain as to why asserting diversity, equity, and inclusion (DEI) initiatives within the urological community is necessary. Perhaps some believe that racial inequities in health care, DEI in the workforce, and the gender gap are no more than “buzz phrases” in our vocabulary. We herein examine such echoed myths and fears about trends in the composition of the U.S. urological workforce with respect to the underrepresented.

Myth: The Pendulum Has Swung Too Far Recruiting URiMs Into Urology

There are some individuals for whom the focus on increasing diversity in urology represents a pendulum that has swung too far. They consider the elimination of board score cutoffs, the transition to pass/fail grading, targeted scholarships and mentorship programs, and a growing emphasis on attracting historically marginalized and underrepresented in medicine (URiM) medical students to urology to be misguided and even “reverse discrimination.” This perspective may seem understandable at a glance. However, the truth is far more complex and reveals deep-rooted issues of implicit and systemic racial biases throughout the medical recruitment, education, and promotion processes. Peeling back the myriad layers of bias requires open-minded and deliberate analysis. As human beings we are not just influenced by our own lived experiences—our upbringing, community, education, and life traumas—but also by our communities’ generational scars and their persisting impacts. Such an exploration is far beyond the scope of this article, but perhaps by reviewing statistics regarding the current composition of the urology workforce, we can begin to illustrate why the pendulum needs to swing so much more.

Looking at a national population level, minority groups have steadily increased over the past decade in proportion to non-Hispanic Whites, with the most recent 2020 U.S. Census showing that Blacks and Hispanic/LatinXs comprise of 13.6% and 18.9% of the U.S. population, respectively.¹ Yet, in urology, these demographic changes have not been reflected in our current workforce. Our most recent AUA Census data from 2021 show that Black urologists comprise only 2.4% of the workforce, and Hispanics only 4.4%. When compared to the 2014 AUA Census data, there has been only marginal change, with Black urologists being 2.5% and Hispanics being 4.1%.²

Some may suggest that this trend will change in the future; unfortunately, the current reality indicates otherwise. On a national level, the proportion of BIPOC (Black, Indigenous, and People of Color) medical student matriculants has remained unchanged for Black men and Hispanics, and actually decreased for Black women.³ Furthermore, when compared to surgery and other specialties, urology has lagged behind in attracting and promoting diverse URiM residents.⁴ Specifically in our field, studies have shown that despite an increase in Hispanic applicants to residency, the number of Hispanic urology residents has essentially remained stable over the past decade.⁵ Similarly, the proportion of Black residents has not changed at all, while the overall number of urology residency positions has increased by 66% during this time. The most recent 2023 Urology Match results show some progress for Hispanic applicants, but much work still remains to improve the pipeline of URiM and particularly Black urology applicants into our field. Relative Match rates for Black and Hispanic applicants are still lower than for White or Asian candidates. White and Asian individuals comprised 54.1% and 20.1% of all candidates, vs 58.5% and 20.9% of matched applicants, respectively, while Black and Hispanic students were 7.3% and 14% of candidates, but only 5.7% and 11.5% of matched applicants, respectively.⁶

Individuals may insinuate that the lack of matched URiM residency candidates is due to less qualified applicants or that URiM students are more interested in other fields. Those arguing the former ignore the underlying reality. Studies have shown that racial disparities exist in all aspects of medical student grading, even when adjusting for other confounding variables such as standardized shelf exams and Step 1 scores.⁷ Review of subjective descriptions within clerkship evaluations and MSPE (Medical Student Performance Evaluation) summaries have been shown to favor White and male students over URiMs, with White students more commonly being referred to as “exceptional” while Black students merely as “competent.”⁸ Induction into AOA (Alpha Omega Alpha) honor society likewise has favored White students over URiMs. A matched cohort study controlling for clerkship grades and Step 1 scores found that Black students were only one-third as likely to be inducted into AOA as similar non-Black peers.⁹

As a urological community, we can do a better job of attracting URiM medical students to our field. One of the potential urology pipeline issues may be a shortage of race-concordant mentorship, which is of particular importance to URiM medical students. URiM students are significantly more likely to deem race-concordant mentorship as “extremely/very important” (73%) as compared to their non-URiM peers (9%).¹⁰ With a lack of congruent mentorship, URiM may indeed choose to seek out other areas of specialty than urology. To address mentorship, we must also acknowledge that URiM faculty can face barriers to promotion that non-URiM faculty do not. Studies have shown that even adjusting for such confounding variables as NIH grant status, minority faculty are promoted at lower rates than White faculty.^11,12 URiM faculty also experience additional burdens that may limit their advancement. The so-called “minority tax” describes a phenomenon that many URiM faculty have experienced. A “tax” of extra responsibilities is often placed on URiM faculty in addressing diversity through their institutions. Being asked to sit on DEI committees, perform community engagement, and clinical work in underserved areas fall disproportionately on URiM faculty, yet are not valued financially or as promotion-earning activities.¹³ The promotion disparity may in turn create a vicious cycle of mentorship scarcity and lack of trainees.

Myth: There Is No Gender Gap in Urology

Women are increasingly represented among urological trainees and now comprise about 10.9% of the urological workforce.² This trend is reassuring, but still inadequate. Some would counter that as a specialty urology is doing better than other surgical specialties at increasing representation of female surgeons. Likewise, there is an echoed myth that the growing numbers of female urology residents outpace those of other surgical specialties. Hennig and colleagues in their 2023 AUA Annual Meeting abstract, “Closing the Gender Gap in Urology and Other Surgical Specialties,” report that the number of female/nonbinary/transgender identified residents was highest in general surgery and with the greatest overall increase of 7.4% over 5 years.¹⁴ Urology, neurosurgery, and orthopedic surgery had the lowest percentage increases overall, only ∼3% over 5 years. The proportional increase from 2017 to 2022 was higher in neurosurgery and orthopedic surgery (17.2% and 19.7%, respectively) than urology (11.9%). On a positive note, since 2020 there has been an upward trend in female match rates; in 2023 a higher percentage of female participants matched with programs (81%) as compared to their male counterparts (73%).⁶

Conversely, women remain underrepresented at the highest levels of organizational leadership and within academic urology, comprising only 6% of urology chairs. Furthermore, a number of studies document a delay in academic promotion of female urology colleagues over their male counterparts with similar credentials.¹⁵ Women are less frequently invited to moderate and speak at academic meetings and are also underrepresented in leadership positions within specialty societies, the AUA sections and the AUA at large.^16,17 There is a positive trend in the increasing number of women AUA committee chairs and speakerships, but there has yet to be a woman secretary or president of the AUA.

Beyond academic promotion, gender disparities also exist in compensation. Female physicians earn less than males in every medical specialty, and the gender pay gap in urology is well documented in the literature. North et al examined 2017 AUA Census data and confirmed that men were twice as likely to make over $350,000 as women (OR 2.01, P = .02) despite similar hours worked.¹⁸ In a separate survey-based study, Spencer et al elicited responses from 848 urologists and found when adjusting for factors including work hours, call frequency, age, practice setting, fellowship training, and advanced practitioner support, female urologists’ salaries were still $76,321 less than men.¹⁹

So, is there really no gender gap?

Myth: LGBTQIA+ Urologists Feel Welcome in Urology

As a field, we are often on the forefront of caring for the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others (LGBTQIA+) community, especially through our pediatric urological and transgender care. As a result, we may assume that LGBTQIA+ members of the urological workforce feel welcome and comfortable within our field. However our understanding of workforce issues facing LGBTQIA+ urologists is lacking. The AUA Census is moving in the right direction and now includes questions about gender identity and sexual orientation. The 2021 AUA Census for the first time has published data on LGBTQIA+ demographics in the workforce; unfortunately, the data are lacking. For gender identity, the 2021 Census reported 48 individuals with a nonbinary, transgender, or other gender identity out of 13,000+ urologists, far less even than those who prefer not to answer.² Sexual orientation data are similarly inadequate, with 1.5% of urologists identifying as gay or lesbian, 1.2% as other terms, and 5.6% who prefer not to answer. Similarly, the numbers of nonbinary and transgender urology applicants are low: 2023 Urology Match results reveal 2 nonbinary and 2 transgender trainees who matched with urology residency programs.⁶

While reporting one’s identity in surveys and in the professional setting is an individual choice, we need to work on creating a safe space for individuals to feel comfortable being themselves and bringing up potential issues facing their community. Long-standing societal taboos on gender identity and sexual orientation remain ingrained; but for all members of our urological community to thrive, it behooves us to understand the issues affecting each one of us.

Conclusion

As the U.S. population ages, there will continue to be an acute need for urologists. Our workforce has been projected to have a 46% shortage to meet the needs of our population by 2035.²⁰ Thus, there remain plenty of opportunities for everyone to succeed. Improving representation in urology is not simply a workforce issue, but also a patient health outcomes one. Racial health inequities have been widely established in urology, whether in prostate cancer, stone disease, or incontinence, with significant implications for patient care.^21-23 Studies have demonstrated that a diverse physician workforce results in improved health outcomes and satisfaction for patients.^24,25 The importance of improving diverse representation is therefore not simply academic, but a matter of great clinical relevance. We hope debunking these myths will help readers appreciate the need for swinging the pendulum even more.

JSH and LB share equal contribution to this article.