Gender and East-West disparities in German neurosurgical training leadership.

Leadership in neurosurgical training is pivotal for educational quality and workforce development, yet gender and regional disparities remain poorly characterized in Germany. A nationwide cross-sectional study analyzed publicly available data from all 17 state medical chambers. Neurosurgical training program directors (TPDs) were identified, and data were collected on gender, shared training authorizations, and maximum approved training duration. Comparisons between the Old (former West) and New (former East) German states were performed using chi-square and Mann-Whitney U tests. A total of 329 TPDs were identified, of whom 26 (7.9%) were women and 303 (92.1%) men. Female representation did not differ significantly between regions (Old States 8.5% vs. New States 5.2%; p = 0.40). Shared training authorizations were significantly more frequent in the Old States (46.9%) than in the New States (20.7%; p < 0.001). Among female TPDs, 42.3% held shared authorizations, though no female-only arrangements existed. The median training duration authorized was 27 months overall (female 39 vs. male 24; p = 0.081). Only 37.6% of training sites offered the full 72-month curriculum required for certification, while 25.9% operated exclusively as outpatient centers. Women remain markedly underrepresented in German neurosurgical training leadership. Regional variation in shared authorizations reflects the predominance of private hospital networks in western Germany rather than differences in educational culture. Addressing these disparities will require targeted mentorship, transparent advancement pathways, and infrastructural investment to promote equitable leadership representation and standardized national training capacity.