Gender diversity within medicine has advanced substantially over the past several decades, yet neurosurgery remains one of the most gender-imbalanced specialties worldwide. Despite women comprising roughly 50% of medical school graduates, they account for only 10–20% of neurosurgery residents and fewer than 10% of practicing neurosurgeons globally [[1], [2], [3], [4]]. Historical barriers — including long training duration, unpredictable schedules, implicit bias, and limited mentorship — have restricted women’s access to senior positions [[5], [6], [7]].

In several high-income regions, structured recruitment and diversity initiatives have improved early-career participation, though progress remains uneven across countries and institutions.

In North America, the proportion of female neurosurgery residents has increased from 12% in 2000 to approximately 20% in 2022 [2] In Europe, the EANS Diversity Task Force 2024 found that women represented 22% of residents and 21% of consultants, but only 4.3% of department heads [1]. Data from Asia-Pacific and the Middle East remain lower still, with female participation ranging from 8% in Japan to 15% in Turkey [3,7,8].

Although recruitment at the trainee level has improved, advancement to senior academic and leadership positions remains markedly limited, a pattern commonly described as the “leaky pipeline.” Importantly, current leadership demographics reflect training cohorts from previous decades, when women comprised far smaller proportions of neurosurgical trainees, and therefore must be interpreted in historical context.

Academic neurosurgery mirrors this structural imbalance. Bibliometric analyses show that women constitute 16–18% of first authors but only 8–10% of senior authors in major neurosurgical journals [[9], [10], [11], [12]]. Studies have also demonstrated that when a female senior author is present, the probability of a female first author doubles, reflecting the impact of gender-specific mentorship [13,14].

Despite this positive mentorship effect, women remain underrepresented in editorial boards, grant review bodies, and neurosurgical society leadership, where representation commonly remains below 10%. This limited presence in gatekeeping roles restricts opportunities for academic advancement and visibility [5,15].

Efforts to address inequity have accelerated. Organizations such as the Women in Neurosurgery (WINS) committees of the World Federation of Neurosurgical Societies (WFNS) and the European Association of Neurosurgical Societies (EANS) have prioritized mentorship, leadership development, and visibility initiatives. However, the impact of these interventions remains difficult to assess due to inconsistent reporting, substantial regional data gaps, and methodological heterogeneity across published studies.

Nevertheless, available data remain fragmented across institutions, national audits, or journal-specific bibliometric studies. Few syntheses have integrated workforce, leadership, and authorship trends into a unified framework

To quantify gender representation at each stage of neurosurgical training and leadership globally;

To evaluate trends in authorship and editorial participation across neurosurgical journals from 2000 to 2025; and

To examine the association between female senior authorship and female first authorship as a measure of mentorship and academic propagation.

By integrating heterogeneous global datasets and applying stratified analyses to improve comparability, this review offers a comprehensive and policy-relevant evaluation of gender equity in neurosurgery and highlights areas requiring targeted structural reform.