Pioneer is, according to the Royal Spanish Academy, the person who takes the first steps in any human activity. In the relatively short history of Spanish nephrology, among the pioneers who created the Spanish Society of Nephrology (SEN) in 1964 was Dr. M. Teresa D’Ocon. From that early SEN constituted by 125 males (M) and only one female (F), at present (February 2023) female nephrologists account for 58% of SEN members (1604 M vs. 1163 F), which implies that the contribution of women to the development of nephrology in Spain is unquestionable and probably decisive. However, the low representation of women, when we move up the hierarchical scale and in positions of responsibility, is still very striking.

According to data from the statistics from Ministry of Universities, in Spain there is a higher percentage of female medical students (50,499 F vs. 25,455 M; 66.5%), this female predominance is reversed as one progresses up the academic ladder, so that at present only Elvira Fernández Giráldez has achieved the degree of Full Professor in Nephrology.

Accordingly, women account for barely 20% of senior management positions. Not only do women usually have to prove themselves more valuable than men to reach the same positions, but there is also a certain reluctance on their part to apply for certain positions because of the fear to break the weak balance between family and professional duties. In addition, long working hours and the burden of on-call duties make women give up some opportunities in favor of family stability. This is the price of motherhood in a country with a crude birth rate in 2022 at a minimum (7.12 births per 1000 inhabitants) and in sharp decline (1.07% lower than the previous year),1 this is according to data from the National Institute of Statistics.

It is a pending task in our environment to break these differences through the incorporation of fundamental values in parity and transforming the myth of conciliation into a reality. This work is concerns both men and women, since feminism is not about looking for culprits, nor about making enemies, but about seeking equality, based on personal capacity and individual merit without forgetting that, in order to be equal, we need to have the same opportunities.

Elena Masera was the first woman officially registered in medical school in Spain in 1872. Her daring even required the express authorization of the then King of Spain. The delay of more than 3 years in the authorization to take the licensure exam, made her finally give up and end up teaching.

In the field of nephrology, Dr. D’Ocon, trained in Internal Medicine, initiated several tracks in nephrology. First, in 1962, she became the first Head of Nephrology Service at the Hospital Clínico de Madrid. Secondly, She was the treasurer (1964–1976) and the only female member of the board of directors of the founders of the SEN. After her, the SEN would not have female representation in the board again for 20 years (1987), with M. Dolores Jarillo as a member (1987–1993), then Fuensanta Moreno (1996–2002) with María Antonia Álvarez de Lara and finally Concepción Laviades (2002–2008). The uprising in the female presence in the SEN began to take shape in 2008 when 4 women joined the board with relevant positions: Isabel Martínez (vice-president), María Dolores del Pino y Pino (treasurer), Gema Fernández Fresnedo and Elvira Fernández Giráldez (members). This transformation materialized in 2014 when Dr. del Pino y Pino, became president of the SEN. Her baton was immediately picked up by Patricia de Sequera, who in 2020 achieved complete gender parity within the current board of directors.

The winds of change are also being observed in the 14 regional and local nephrology societies, developed between 1963 and 2004. While initially there was only one woman (Rosa Ranero of the Galician Society) on a board of directors, today we are close to reaching parity and 6 regional societies have a female president: Nuria Areste in the Andalusian, Guadalupe Tabernero in the Castilian-Asturleonese, Laia Sans in the Catalan, María Marques in the Madrid, María Luisa Muñiz in the North and Laura Patricia Sahabala in the Rioja.

However, recognition of the work of women in the development of nephrology is scarce: after 55 years of history, only Dr. del Pino and Dr. Fernández Giráldez, in 2021 and 2022, respectively, have had the honor of becoming the first women with the distinction of Honorary Member of the SEN, after the appointment of 55 men (3.5% M).

The European Renal Association (ERA), founded in 1963 by 3 men, had 5 women as attendees at its first symposium (5 F vs. 77 M; 6% F). The ERA, currently has 5813 members, maintains low female representation on its Council (2 F vs. 13 M in 2023; 13% F) among whom the Spanish Roser Torra is noteworthy.

Another pioneer, María José Soler, elected member of the ERA Council, is currently editor-in-chief of the Clinical Kidney Journal, being the only Spanish woman awarded as a distinguished member of the ERA.

Our specialty was officially recognized in 1977, and before the MIR program was established in 1976, there were already women nephrologists as attending physicians or on training the major hospitals in the country that had a nephrology service: Ana Gonzalo in Bellvitge, and later in the Ramón y Cajal Hospital together with Nieves Gallego, Teresa González in Bellvitge, Isabel Úbeda in the Hospital Clínico de San Carlos, Carmen Riñón in La Paz and Rosa Jofre in the Hospital Provincial de Madrid (today Gregorio Marañón). At the Hospital 12 de Octubre Teresa Ortuño, Dolores Jarillo, Carmen Bernis, Ana Vigil and many others.

The Hospital Clínico de San Carlos in Madrid has been a pioneer in the access of female nephrologists to executive positions. Dr. D’Ocon and later M. Dolores Prat led the service at its creation and again today it has a woman as head: Ana Sánchez Fructuoso.

The progressive increase in roles of women of Spanish Nephrology and generational turnover have led to women becoming the majority in nephrology clinical care (58% of the staff of the 15 public hospitals with the highest reputation and 60% of nephrology residents) (Fig. 1). However, men continue to outnumber women in management positions. According to SEN data from January 2023, only 38% of service heads in public hospitals are held by women (68 F vs. 112 M), whereas 57% of dialysis centers have a woman in charge (41 F vs. 29 M) (Fig. 1).

Fig. 1.

Representation of women in nephrology. Data expressed as a percentage.

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Surprisingly, if we analyze the gender percentages according to age in SEN members, men, who occupy more positions of greater responsibility as compared to women, only begin to be in the majority after the age of 60 (60.5% M). Thus, in the coming years we will learn if it is just a generational replacement (Fig. 2).

Fig. 2.

Percentage distribution of male and female SEN members by age group. Data expressed as a percentage.

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The presence of women in the journal Nefrología continues to be scarce. To date, in its 42 years, it has never been directed by a woman. From its creation in 1981 until 1989, there was no female presence on the editorial or editorial board, until the incorporation of the pioneering Nieves Gallego, Dolores Jarillo and Emma Huarte (3 W vs. 37 M). In 1993, Carmen Bernis, Soledad García de Vinuesa and M. Teresa González, among others, joined the editorial committee (6 F vs. 54 M) and in 1995, Blanca Miranda joined the editorial committee (1 F vs.10 M).

The percentage participation of women in the editorial committees of nephrology journals is better overall (“NEFROLOGIA” 19%; “JASN” 26.3% and “NDT” 21%), with these percentages soaring when the journals have a woman as editorial director (AJKD 41.2% and CKJ 40.3%).

Unfortunately, the low representation of women goes beyond the editorial boards and is also evident in the authorship of publications. After reviewing the first annual issue of the main nephrology journals (NEFROLOGIA, AJKD, CJASN and NDT) for the years 2010 and 2020, it was observed with hope that the percentage of first authors has risen from 34.6% in 2010 to 42.1% in 2020. These differences are much more pronounced in the meager percentage of last authors (17.9% in 2010 and 22.9% in 2020).

Nephrology is a very active specialty in clinical research, and the discrete participation of women has been progressively increasing.

At the last SEN congress (Granada 2022), despite the fact that women were the majority in the local organizing committee (73%), our participation in the official program was reduced to 42.6% of the presentations and 43% of the moderations, dropping drastically in the industry forums (37% of the moderations and 31.8% of the presentations) (Fig. 1).

Gender disparity in all academic disciplines of undergraduate teaching is a complex and well-recognized global problem2 with several causes. The inherent conservatism of public universities, together with archaic selection processes for associate professors with sometimes outdated scales, may be the cause. In addition, it is worth noting that tenured or tenure-track faculty constitute only 23% of the total, and teaching in many faculties relies exclusively on associate professors.3

In undergraduate teaching in nephrology, we only have two precedents. Elvira Fernández Giráldez became in 2016 the first woman full professor of nephrology, and the only one to date, at the University of Lleida. She was also director of the Institute for Biomedical Research of Lleida. The second, Ana Sánchez Fructuoso, is the only active full professor of nephrology (1 F vs. 7 M).

However, it is to be expected that, with the inevitable generational change, there will be a fair and reasonable female presence. In the last 3 years, 6 professors (full and associate professors) have become emeritus. Before 2025 are scheduled to retire 7 of the 10 current full professors, and 5 out of the 12 associate professors.

Interestedly, in postgraduate teaching, i.e., tutoring of residents in training, there has been a large majority of female nephrology resident tutors for years (66%). Although the generational changeover could justify this difference, we should not lose sight of the fact that the tutoring of residents is not remunerated financially.

The good news is that the National Commission of the Specialty is currently chaired by a woman: Gema Fernández Fresnedo, Marqués de Valdecilla University Hospital in Santander. And that in a context of transformation of teaching in general and university teaching in particular, the SEN has created the University Working Group of which Nuria García Fernández, Carmen Díaz Corte, María Dolores del Pino, Ana Sánchez Fructuoso, Mercedes Salgueira and Patricia de Sequera are members representing female nephrologists (6 F vs. 20 M; 23%).

Taking advantage of this editorial, the authors would like to remember all these women who have been milestones in our specialty, thanks to whom today’s women nephrologists can practice our profession with equality, and are our role models. However, we still have to improve participation in university teaching and research, as well as their presence in international events and organizations, although we have started on the path to do so. Here men and women must “row” together and society in general must promote and support the necessary measures to facilitate family compromise and real equality between men and women.

We consider that all nephrologists are pioneers in some way, only some were born before and have been paving the way in the specialty. Although all of them are pioneers, it is easy that not all of them werre included in these lines, and we apologize for that.

Intriguingly, this year International Women’s Day (March 8, 2023) and World Kidney Day (March 9, 2023) practically overlapped, so we nephrologists had a double celebration. Our congratulations to all of you for being women and having chosen nephrology as a specialty. Thank you for your dedication and enthusiasm, and we wish you all the best because the future of nephrology is in your hands.

The authors declare that they have not received funding for the writing of this editorial.