The Surgical Glass Ceiling: A Retrospective Observational Study of Gender Representation from Residency Programs to Academic Positions in Italy

BACKGROUND: Women constitute the majority of medical graduates in Italy, yet remain markedly underrepresented in surgery, particularly in high-intensity specialties and senior academic ranks. This imbalance threatens the sustainability of the surgical workforce and may compromise equitable access to high-quality care. We aimed to quantify sex disparities across the continuum of surgical training, specialization, and academia. STUDY DESIGN: We conducted a national, retrospective, observational study using 3 databases: Cineca (residents, 2017 to 2023), FNOMCeO (specialists, 1983 to 2023), and the Ministry of University and Research (academic staff, 2024). Sex distribution was examined across specialties, ranks, and age groups. Multinomial logistic regression was used to evaluate the association between sex and academic promotion, adjusting for age, region, and research productivity (h-index). RESULTS: From 2017 to 2023, 15,189 surgical residents were identified; women comprised 49.5% overall but only 42.6% after normalization for sex ratio among medical graduates. Among surgical specialists, the proportion of women rose from 20.6% in 1983 to 46.9% in 2023, but parity has not been achieved. Underrepresentation was most pronounced in urology (21.1%) and orthopaedics (21.6%). Of 1,753 academic surgeons in 2024, only 16.5% were women, with representation declining by rank (29.5% assistant, 14.7% associate, 6.9% full professor). Men were more likely to attain associate (adjusted odds ratio 1.86, 95% CI 1.32 to 2.62) and full professorships (adjusted odds ratio 7.90, 95% CI 4.22 to 14.77). CONCLUSIONS: Despite progress, women remain underrepresented in surgical specialties and disproportionately excluded from senior academic ranks. Scalable interventions, such as mentorship, transparent promotion systems, and supportive work-life policies, are urgently needed to dismantle the "surgical glass ceiling" and safeguard the future surgical workforce.