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 gender disparities across the continuum of surgical training, specialization, and academia. STUDY DESIGN We performed a national retrospective observational study using three databases: Cineca (residents, 2017-2023), FNOMCeO (specialists, 1983-2023), and the Ministry of University and Research (academic staff, 2024). Gender distribution was examined across specialties, ranks, and age groups. Multinomial logistic regression evaluated the association between gender 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. Underrepresentation was most pronounced in urology (21.1%) and orthopedics (21.6%). Among surgical specialists, the proportion of women rose from 20.6% in 1983 to 46.9% in 2023, but parity has not been achieved. 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 (aOR 1.86, 95% CI 1.32-2.62) and full professorships (aOR 7.90, 95% CI 4.22-14.77). CONCLUSION Despite progress, women remain underrepresented in surgical specialties and disproportionately excluded from senior academic ranks. Scalable interventions, like mentorship, transparent promotion systems, and supportive work-life policies, are urgently needed to dismantle the "surgical glass ceiling" and safeguard the future surgical workforce.