Expanding the global dialogue regarding gender equity in urology

While the number of women entering urology has grown over the past decade – particularly in high-income countries (HICs) [1, 2] – significant gaps remain in our understanding of gender equity in urology on a global scale. This commentary draws on existing literature to explore geographical variations in gender representation and examine shared professional barriers including discrimination, academic promotion and obstetric concerns. Although this was not a systematic review, a central aim was to examine the literature and provoke critical reflection on data gaps and underrepresentation of women urologists in low- and middle-income countries (LMICs), as defined by the World Bank's Country and Lending Groups classification [3]. The terms ‘female’ and ‘woman/women’ are used as they appear in the sources referenced throughout the article, recognising that both terms are commonly employed in the context of gender equity discussions. In 2023, 12% of practising urologists in the United States were female, a steady annual growth from 8% in 2014 [1]. While this serves as a critical benchmark for diversifying the urological workforce, our community has little insight into gender diversity beyond North America. Gender-disaggregated data are essential for understanding national labour trends including migration, attrition and retirement, as well as the needs of and barriers facing respective workforce members [4]. In Australasia, representation is comparable to that in the United States, with 13% of urologists and 30% of trainees being women [5]. This pattern of greater female representation in earlier career stages is evident in the European Association of Urology (EAU) as well, where approximately 18% of consultant members are female, and the proportion of female trainees in the region is at least double that [2]. However, national-level data should not be overlooked as regional variations may reveal distinct differences in representation. For example, 67% of urology trainees in Spain are female, compared to 28% and 33% of trainees in Italy and the UK, respectively [2]. There is a paucity of published data pertaining to the distribution of women urologists in LMICs; however, existing literature suggests the prevalence is lower than in HICs. In Colombia and Brazil, approximately 9% and 3% of board-certified urologists are female, respectively [6, 7]. In India, this proportion is approximately 1% (~50 female urologists) [8]. The number of female urologists in the Middle East, which comprises both HICs and LMICs, ranges from 0 to 35 depending on the country [9]. Understanding the urological workforce in Africa is especially critical, as the region faces one of the highest burdens of urological disease [10]. Often either the sole or one of few urologists in their region, approximately 5% of urologists in East, Central and Southern Africa are female [11]. In 2022, an estimated 20 women were in the process of training to deliver care to millions of patients who currently lack access, although this number has not since been updated publicly [12]. Despite geographical barriers, research suggests that women urologists report unique experiences both in training and practice. The prevalence of discrimination and harassment of women in urology remains distinctly high across international borders. Among the largest non-US sample, 56% of French female urology residents cited gender-based work discrimination, compared to 6% of their male peers [13]. Similar figures have been observed in India and Canada, where 55% and 65% of women urologists, respectively, report gender discrimination, mainly from patients and physician colleagues [8, 14]. Detailed data pertaining to the harassment of urologists is sparse, likely due to the sensitivity of the issue and fear of repercussions. However, survey data show that anywhere from 63% to 75% of female urologists have experienced sexual harassment at work, with higher rates among trainees (MP57-01, presented at AUA 2023) [15]. The 2023 American Urological Association (AUA) census found that female urologists were more likely to practise in an academic centre than their male counterparts [1], yet persistent disparities in academic representation exist for women urologists worldwide. Within a representative sample of major international urology conferences, Teoh et al. [16] calculated that 64% of conference sessions had zero representation from female urologists. Even for subspecialties with greater gender parity, such as functional/female urology, the gender gap among speakers approaches 30% [17]. With respect to authorship, there has been a general rise in female first and last authorship; however, growth remains slow for certain subspecialties, such as endourology and uro-oncology [18]. Notably, gender concordance appears to play an important role in these trends, with female first authors significantly more likely to be paired with a female senior author [18]. There is a concerning body of literature describing distinct obstetric challenges encountered by women urologists globally. Recently, a survey of 4600 female physicians found that urologists remain significantly more likely to experience a miscarriage or preterm birth relative to their peers [19]. The general incidence of pregnancy-related complications among women urologists is high in other countries as well, including up to 30% in Canada [14]. It has also been well documented that women urologists are more likely to use assisted reproductive technology than the general population [19]. In addition to physical obstetric complications, women urologists report a feeling of lack of autonomy over when to have children. One quarter of female French urology trainees felt it was not possible to have a family at the time they desired to, while one third of Indian female urologists felt that their career compromised their family/personal life [8, 13]. Despite previously described barriers, urologists remain united in their efforts to improve gender disparities for future generations. Organisations such as the EAU have formed equity, diversity and inclusion committees to advise on mentorship and speaker diversification [20]. With regional parental leave varying widely, there are growing calls for transparent, gender-neutral policies that support both trainees and urologists in taking necessary time off [21]. In addition, there has been a rising tide of evidence spotlighting radiation safety for pregnant urologists [22]. Male-only panels at academic conferences have been criticised via international social media campaigns in Australia, Kenya, Pakistan and beyond [16]. Notably, this progress would not have been possible without allyship from male colleagues who have also challenged the status quo. Acknowledging the limited number of senior women urologists, gender-discordant mentorship and sponsorship remains critical to achieving gender equity. Women urologists from LMICs represent a distinct, unmeasured asset to the urology profession. Often one of few in their region, they face challenges related to professional isolation, lack of mentorship and unique cultural barriers; however, we know much less about their experiences and distinctive needs [12]. The Society of Women in Urology (SWIU) amplified the global voices of women urologists in their dedicated #SWIUGlobalCommunity interview series in 2024. In addition, members of SWIU have partnered with Women in Urology Africa to engage in bidirectional mentorship across urological subspecialties. The AUA Global Leadership Program has fostered partnerships with women urologists from Brazil, Mexico, Colombia, Peru and beyond [23]. Finally, in 2023, the Société Internationale d'Urologie annual congress hosted a dynamic podium session of women urologists from around the world discussing their respective experiences [24]. Strengthening international collaboration and mentorship is a vital strategy to empower women urologists, particularly from LMICs, to thrive in our global urology community. Globally, women urologists remain few in number yet share distinct, documented experiences related to discrimination, academic promotion and pregnancy. While representation has increased in many HICs, far less is known about the experiences and contributions of women urologists in LMICs, where professional isolation and resource constraints may further compound gender-based barriers. Advancing gender equity in urology requires intentional international collaboration, inclusive partnerships and thoughtful mentorship. This commentary is not a systematic review and does not include data or perspectives specific to transgender women, both of which are important areas for future scholarship. Continued efforts to amplify diverse voices and build equitable systems will strengthen the global urology community for all. None to disclose. The authors would like to express their gratitude to the SWIU for their commitment to supporting, promoting, and sponsoring women urologists globally. S.T. is a consultant for Boston Scientific. The remaining authors have no disclosures.