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GLOBAL STATE OF UROLOGY Women in Surgery: The Changing Faces of Urology in Australasia

By: Cynthia O’Sullivan, FRACS (Urol), PGDipOMG, MBChB, Auckland City Hospital, New Zealand | Posted on: 18 Mar 2024

As my 5-year journey in urology training comes to its conclusion, it’s a poignant moment to reflect not only on the challenges and triumphs encountered along the way, but also on the opportunities that have shaped my perspective. Urology training in New Zealand, under the Royal Australasian College of Surgeons (RACS) and the Urological Society of Australia and New Zealand (USANZ), follows a competitive selection process, offering a comprehensive 5-year program. This article aims to explore the landscape of urology training in Australasia, particularly focusing on the challenges faced by female trainees, the strides made in representation, and the ongoing initiatives to create a more inclusive environment.

Commencing with a competitive selection process, the 5-year urology training program follows several years of prior clinical experience, akin to the basic training program in the British system. In 2019 at the start of my training, there were 19 trainees appointed across both Australia and New Zealand, with just over 30% being female. The collaborative training program between the 2 countries fosters enduring collegial relationships, treating New Zealand similar to a “state” of Australia. Trainees move across various health districts yearly, exposing them to diverse communities and health care settings.

There are many challenges for urology and training in Australasia that could be discussed, such as centralization of services, integrating robotics uniformly among trainees and populations, and workforce planning for rural communities. However, as I sit here and write this article at 39+ weeks pregnant, I find myself contemplating the unique challenges faced by female trainees in a predominantly male-dominated field. Being a female trainee in urology has allowed me to forge connections with inspiring female role models who have mentored me through these challenges.

Witnessing Professor Helen O’Connell become the first female President-elect of USANZ at the Annual Scientific Meeting in Melbourne in February 2023 was a groundbreaking moment. Professor O’Connell holds the distinction of being not only the first female USANZ President, but was also the trailblazing first female urologist in Australasia when she completed training in 1994. This historic moment was complemented by the presence of the first female British Association of Urology President, Miss Jo Creswell, and a panel of accomplished female surgeons.

The saying “You cannot be what you cannot see” holds true, and the current era is one of increased visibility. The gender shift in medical students is evident, with female medical students outnumbering males in New Zealand.1 However, this shift is not entirely reflected in specialist roles, particularly in surgery.2 A recent article in Australian and New Zealand Journal of Surgery revealed that only 13% of urologists in Australasia are female, mirroring a similar trend in the UK.3,4 Despite a steady increase in women across all subspecialties based on the current trends, it is predicted to take 53 years to increase representation to 40% within urology. Although orthopedics and cardiothoracics are estimated to take an appalling 140 years to reach this mark, urology is the next slowest in progression.3

The gender disparity in urology, as in many surgical specialties, is influenced by various factors contributing to the leaky pipeline from medical school to specialist practice. Issues such as gender discrimination, inflexible working hours, unpredictable surgical lifestyle, bullying, sexual harassment, and a lack of same-gender mentorship contribute to this gap. To address these challenges, RACS introduced a Diversity and Inclusion Plan in 2016, aiming to understand and mitigate barriers for females, increase representation in surgery, and modify training options.5

The USANZ Annual Scientific Meeting serves as an exemplary showcase of representation, featuring the first female-elect, strong female panels, and a multitude of female mentors. Efforts to increase female representation at conferences, reducing the prevalence of all-male panels (“manels”), have been notable.6 Advocacy groups like Surgical Women in Australia and New Zealand, chaired by Dr Anita Clarke, the second female urologist in Australasia, work toward fostering mentorship and support. International leaders, including Miss Jo Creswell, and Dr Anne Cameron, the previous president of the Society of Women in Urology, further contributed to the diverse and inclusive environment at such events.

The intersection of postgraduate surgical training with peak fertility years is a nuanced and often unspoken challenge for many female surgeons. As the demands of surgical training intensify, female surgeons find themselves navigating the delicate balance between career aspirations and family planning. Studies consistently highlight that female surgeons tend to experience a unique set of challenges, including fewer children, delayed parenthood, higher rates of infertility, and an increased risk of pregnancy-associated complications.7

A UK study revealed that a staggering 56% of female respondents had delayed parenthood due to the demands of their training, with over 80% expressing regret over this decision.7 The timing of pregnancy often becomes a carefully orchestrated maneuver, dictated by the demands of the job rather than personal preference.

I have been fortunate to navigate this challenging terrain with supportive mentors (both female and male) who have encouraged me to prioritize my family planning. However, the reality remains that the demands of surgical training such as fellowship examinations, moving yearly, and the on-call roster have compelled me and many others to delay family plans.

Engaging with fellow female trainees at the inaugural Global Residents Leadership Retreat provided a valuable platform to openly discuss maternity leave and the challenges associated with pregnancy during training. International perspectives varied, with counterparts sharing experiences ranging from taking extended maternity leave in Germany to more limited leave options in the US, where the norm is often around 8 weeks during residency.8

While the structure of the Australasian training program allows for a trainee to take a training year off, providing up to 12 months of maternity or paternity leave if the primary caregiver is the father, there is recognition that improvements can still be made. Returning to work after such leave introduces another set of considerations, including the physical and mental barriers that may impede a smooth reintegration into the demanding surgical environment.

Recognizing these challenges, RACS has taken proactive steps by redesigning training models to support return-to-work programs, part-time, or flexible training options.5 However, while this is great in theory, it remains an ongoing process of development, and the barriers faced by female surgeons need to be continually challenged to foster a more inclusive and supportive environment.

As I stand on the precipice of this next chapter in my life, I hope to contribute to the ongoing dialogue on balancing parenthood and surgical training. By sharing experiences and advocating for continued improvements in support structures, we can pave the way for future generations of female surgeons to navigate this complex terrain with greater ease and confidence. The journey, though challenging, is an essential part of the evolving narrative of women in surgery in Australia and New Zealand.

  1. Medical Deans Australia and New Zealand. Student statistics report 2021. 2021. Accessed January 12, 2024.
  2. Medical Council of New Zealand. The New Zealand medical workforce in 2020. 2020. Accessed January 12, 2024.
  3. Graham V, Arora B. Women in surgery: trends in nine surgical specialties. ANZ J Surg. 2023;93(10):2344-2349.
  4. Solomon E, Reeves F, Challacombe B. Women in urology: breaking down the barriers. Trends Urol Mens Health. 2023;14(1):2-4.
  5. Royal Australasian College of Surgeons. Diversity & inclusion plan. 2016. Accessed January 12, 2024.
  6. Graham V, Bray G, Lyon K. Gender diversity in urology scientific meetings: an analysis of the last nine years. ANZ J Surg. 2023;93(10):2357-2362.
  7. Whitburn J, Miah S, Howles S. Pregnancy and parenthood in surgical training: a cross-sectional survey in the UK. Br J Surg. 2023;110(12):1628-1631.
  8. Ernst M. Positive steps and further considerations: an update on parental leave in urology residency. AUANews. 2021;26(11):65.