III. Next on the agenda: gender

Abstract

Let's get one thing out of the way'what is the difference between sex and gender? Sex refers to biological differences such as chromosomes, hormonal profiles, and internal and external sex organs. Gender, on the other hand, describes the characteristics of what is considered masculine or feminine. So gender is essentially the socially defined differences between men and women. It is a bit like gene and environment interactions (nature vs nurture) and just as hard to separate out. In this article, we will use the term ‘gender differences’ as a blanket term for sex and gender differences. The number of female medical students has been steadily increasing, although this varies worldwide as might be expected. Today more than half the graduating doctors are women'and this has been the case for some time1Baerlocher MO Hussain R Bradley J Gender patterns amongst Canadian anesthesiologists.Can J Anesth. 2006; 53: 437-441Crossref PubMed Scopus (11) Google Scholar although women are still not equally represented at senior levels. In Australia in 2009, there were 35.7% women doctors but only 25.4% were specialists (hospital consultants).2Australian Institute of Health and WelfareMedical Labour Force 2009. 2011http://www.aihw.gov.au/publication-detail/?id=10737419680Google Scholar In all the UK universities, the overall figure for female professors is 19%.3Equality Challenge UnitEquality in higher education: statistical report. 2011Google Scholar Even in Iceland, which is considered the most gender equal country in the world4Hausmann R Tyson LD Zahidi S The Global Gender Gap Report. 2011http://www3.weforum.org/docs/WEF_GenderGap_Report_2011.pdfGoogle Scholar with women comprising 46% of elected members of parliament, there are still fewer female than male professors.5Guđmundsson HK The Gender Challenge in Research Funding-Assessing the European National Scenes-Iceland. 2008http://ec.europa.eu/research/science-society/document_library/pdf_06/iceland-research-funding_en.pdfGoogle Scholar The Medical Schools Council survey describing data from 2011 reports that there are 3446 clinical academics in the 34 UK universities with medical schools.6Fitzpatrick S Staffing Levels of Medical Clinical Academics in UK Medical Schools. Medical Schools Council, 2012http://www.medschools.ac.uk/publications/Pages/ClinicalAcademicStaffSurvey2012.aspxGoogle Scholar Women are still the minority at any clinical academic grade and are severely under-represented at the highest grades. There are currently 1162 male professors in clinical medicine at the UK medical schools (all specialities) and only 207 (just more than 15%) are female. The survey further states that the number of female clinical academics has increased by a third since 2004, with a 60% increase at professorial grade and that ‘It is important that both men and women continue to be attracted into careers in clinical academic medicine, and it is clear that the historical gender disparity is being redressed’.6Fitzpatrick S Staffing Levels of Medical Clinical Academics in UK Medical Schools. Medical Schools Council, 2012http://www.medschools.ac.uk/publications/Pages/ClinicalAcademicStaffSurvey2012.aspxGoogle Scholar The study by Cynthia Wong and Marie Stock on the state of play in the USA reported that the percentage of women at full professor grade in anaesthesiology was not significantly different in 2006 to that in 1985.7Wong CA Stock MC The status of women in academic anesthesiology: a progress report.Anesth Analg. 2008; 107: 178-184Crossref PubMed Scopus (44) Google Scholar In 2005, there were 29 chairs of anaesthesia, with 2 vacant posts, at the UK medical schools8Pandit JJ A National Strategy for Academic Anaesthesia. Royal College of Anaesthetists, London2005Google Scholar and two of these were held by women. Today there are four female professors of anaesthesia'interestingly two of these are non-clinical. Call us cynical, but that ‘historical’ gender disparity does not seem to be improving very quickly. There is the same gender difference in authorship of research papers in medicine, although women's contributions have increased over the last decade.9Jagsi R Guancial EA Worobey CC et al.The “gender gap” in authorship of academic medical literature'a 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (615) Google Scholar 10Sidhu R Rajashekhar P Lavin VL et al.The gender imbalance in academic medicine: a study of female authorship in the United Kingdom.J R Soc Med. 2009; 102: 337-342Crossref PubMed Scopus (137) Google Scholar A study published in 2006 reported that of US authors publishing in six prominent medical journals, only ∼16% of senior authors and 29% of first authors of research papers were female.9Jagsi R Guancial EA Worobey CC et al.The “gender gap” in authorship of academic medical literature'a 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (615) Google Scholar A 2009 study of the UK-based journals showed similar results.10Sidhu R Rajashekhar P Lavin VL et al.The gender imbalance in academic medicine: a study of female authorship in the United Kingdom.J R Soc Med. 2009; 102: 337-342Crossref PubMed Scopus (137) Google Scholar Publications provide the main objective record for advancement in academic medicine and credibility for roles such as editorial board or specialized society board memberships and so publication rates can make or break careers. Men publish more papers than women in all areas of science'this is as true today as it was 30-yr ago.11Duch J Zeng XHT Sales-Pardo M Radicchi F Otis S et al.The possible role of resource requirements and academic career-choice risk on gender differences in publication rate and impact.PLoS ONE. 2012; 7: e51332doi:10.1371/journal.pone.0051332Crossref PubMed Scopus (153) Google Scholar 12Cole JR Zuckerman H The productivity puzzle: persistence and changes in patterns of publication of men and women scientists.Adv Motiv Achiev. 1984; 2: 217-258Google Scholar It may be that women produce fewer, but higher ‘quality’ papers, as measured by the number of citations.13Long JS Measures of sex-differences in scientific productivity.Soc Forces. 1992; 71: 159-178Crossref Scopus (271) Google Scholar As such, assessment of research performance based solely on the quantity of papers would tend to favour males, but even when the impact of research is taken into account men may still be favoured as this, and related measures such as h index, is also correlated with quantity.14Webster NR Bibliometrics and assessing performance and worth.Br J Anaesth. 2011; 107: 306-307Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar To ensure that research performance is assessed without such gender bias, a measure that takes into account the relationship between quality and quantity is needed, as has been suggested by Symonds and colleagues.15Symonds MRE Gemmell NJ Braisher TL Gorringe KL Elgar MA Gender differences in publication output: towards an unbiased metric of research performance.PLoS ONE. 2006; 1: e127doi:10.1371/journal.pone.0000127Crossref PubMed Scopus (194) Google Scholar A study of the journal Wiener klinische Wochenschrift from 2001 to 2009 reported that only 5–11% of their reviewers were women and review papers or invited editorials were rarely authored by female researchers.16Heckenberg C Drum L Gender aspects in medical publication'the Wiener klinische Wochenschrift.Wien Klin Wochenschr. 2010; 122: 141-145Crossref PubMed Scopus (30) Google Scholar The British Journal of Anaesthesia does not record whether its reviewers are male or female and so we do not know our referees’ genders unless their names make it obvious. The underrepresentation of women is also reflected in their roles as Editors-in-Chief and editorial board members of medical journals.16Heckenberg C Drum L Gender aspects in medical publication'the Wiener klinische Wochenschrift.Wien Klin Wochenschr. 2010; 122: 141-145Crossref PubMed Scopus (30) Google Scholar, 17Kennedy BL Lin Y Dickstein LJ Women on the editorial boards of major journals.Acad Med. 2001; 76: 849-851Crossref PubMed Scopus (58) Google Scholar, 18Keiser J Utzinger J Singer BH Gender composition of editorial boards of general medical journals.Lancet. 2003; 362: 1336Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 19Jagsi NJ Tarbell NJ Henault LE et al.The representation of women on the editorial boards of major medical journals: a 35-year perspective.Arch Intern Med. 2008; 168: 544-548Crossref PubMed Scopus (95) Google Scholar, 20Amrein K Langmann A Fahrleitner-Pammer A Pieber TR Zollner-Schwetz I Women underrepresented on editorial boards of 60 major medical journals.Gend Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar In 2008, only 11.5% of the editorial board members of 16 prominent biomedical journals were female.19Jagsi NJ Tarbell NJ Henault LE et al.The representation of women on the editorial boards of major medical journals: a 35-year perspective.Arch Intern Med. 2008; 168: 544-548Crossref PubMed Scopus (95) Google Scholar Another paper from 2011 reported that 15.9% of the Editors-in-Chief of 60 top ranked medical journals were female,20Amrein K Langmann A Fahrleitner-Pammer A Pieber TR Zollner-Schwetz I Women underrepresented on editorial boards of 60 major medical journals.Gend Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar and no journal in the anaesthesiology category at that time had a female Editor-in-Chief. The proportion of female editorial board members was only 15.2% in journals in the anaesthesiology category and 7.3% in the critical care category.20Amrein K Langmann A Fahrleitner-Pammer A Pieber TR Zollner-Schwetz I Women underrepresented on editorial boards of 60 major medical journals.Gend Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar These authors also revisited 11 journals that were previously evaluated by others17Kennedy BL Lin Y Dickstein LJ Women on the editorial boards of major journals.Acad Med. 2001; 76: 849-851Crossref PubMed Scopus (58) Google Scholar 19Jagsi NJ Tarbell NJ Henault LE et al.The representation of women on the editorial boards of major medical journals: a 35-year perspective.Arch Intern Med. 2008; 168: 544-548Crossref PubMed Scopus (95) Google Scholar and described some progress in the representation of women on editorial boards in seven of the journals, but disappointingly no change, or even a decrease in the remaining four.20Amrein K Langmann A Fahrleitner-Pammer A Pieber TR Zollner-Schwetz I Women underrepresented on editorial boards of 60 major medical journals.Gend Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar There was no difference in the percentage of female editorial board members in those journals which already had a female Editor-in-Chief compared with journals with male Editors-in-Chief. This is at odds with a comprehensive study of the editorial boards of a large number of management journals who reported that a female Editor-in-Chief had a major impact on editorial board diversity.21Metz I Harzing A-W Gender diversity in editorial boards of management journals.Acad Manag Learn Educ. 2009; 8: 540-557Crossref Scopus (60) Google Scholar The Lancet's international advisory board has had equal representation of men and women for several years18Keiser J Utzinger J Singer BH Gender composition of editorial boards of general medical journals.Lancet. 2003; 362: 1336Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar and the BJA did have a female Editor-in-Chief from 1997 to 2005. We all know that supporting academic anaesthesia is important for the future of our speciality. In the UK in 2007, ∼42% of anaesthetic trainees were female, but only 29% of consultants were female.22Royal College of Anaesthetists Census Report, 2007, Available from http://www.rcoa.ac.uk/tags/census.Google Scholar When considering the Council of the Royal College of Anaesthetists, in 1990–1994, one of 23 (4%) were female and although this figure is the same now, there was a period in 2000–2004 where four of the 23 Council members were female (16%). In 2006, of the editors or associate editors of the American journals Anesthesiology and Anesthesia & Analgesia, 8 and 11% were women, respectively.7Wong CA Stock MC The status of women in academic anesthesiology: a progress report.Anesth Analg. 2008; 107: 178-184Crossref PubMed Scopus (44) Google Scholar The Editorial Board of the British Journal of Anaesthesia currently has two of 10 (20%) female editors, with another woman on the editorial board (9%). The Associate Editorial Board has three women (12.5%). This has seen little improvement in the last 10 yr; in 2002 the Editorial Board had two women and 26 men (7%) and one female editor (the Editor-in-Chief). We have conducted a retrospective analysis of the gender of authors of original research papers published in the British Journal of Anaesthesia in 2011 (volumes 106, numbers 1–6 and 107, numbers 2–6, excluding the July Postgraduate issue and educational supplements). All original research papers, but not editorials, reviews, systematic reviews, and meta-analyses, were included in the analysis. The sex of the first and senior authors (by convention this is usually the last author) was determined, either by accessing publically available information or by contacting the corresponding author by email. In some cases the senior author was the first author, in which case the author was only counted once, as first author. The total number of articles was 198, of which 10 were excluded because of incomplete information. Of the 188 eligible articles, 131 (69.7%) of the first authors were male, and 57 (30.3%) were female (P<0.01, χ2). The majority of papers had male first and senior authors; the next most common scenario was female first author and male second author, compared with only ∼7% where either both first and senior authors were female or the first author was male and the senior author was female (Fig. 1). The ratios were very similar for each issue of the journal, with a median (range) of 17 (15–19) original research articles per issue, of which 11 (10–16) had male first authors and 5 (2–7) had female first authors. These figures are similar to previous studies.7Wong CA Stock MC The status of women in academic anesthesiology: a progress report.Anesth Analg. 2008; 107: 178-184Crossref PubMed Scopus (44) Google Scholar 9Jagsi R Guancial EA Worobey CC et al.The “gender gap” in authorship of academic medical literature'a 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (615) Google Scholar 10Sidhu R Rajashekhar P Lavin VL et al.The gender imbalance in academic medicine: a study of female authorship in the United Kingdom.J R Soc Med. 2009; 102: 337-342Crossref PubMed Scopus (137) Google Scholar The representation of women both on the boards of specialist societies and journals does not mirror the composition of medical specialties, although some clinical areas are ‘less worse’ than others. As such it is simply unfair. There is also evidence that gender diverse teams are more innovative than single sex ones, so that equality issues can impact on quality and innovation in science research.23Committee on Maximizing the Potential of Women in Academic Science and Engineering. National Academy of Sciences, National Academy of Engineering, and Institute of Medicine Beyond Bias and BarriersFulfilling the Potential of Women in Academic Science and Engineering. National Academy of Sciences, Washington, DC2007Google Scholar, 24Marsh J Women in science – what's the world missing?.Eur Sci Editing. 2012; 38: 2Google Scholar, 25http://www.30percentclub.org.uk (accessed 18 February 2013).Google Scholar In their report from 2006, the National Academy of Sciences stated that women's progress in science is attributable to ‘unintentional biases and outmoded institutional structures’ and called for a ‘reasonable representation of women on editorial boards’.23Committee on Maximizing the Potential of Women in Academic Science and Engineering. National Academy of Sciences, National Academy of Engineering, and Institute of Medicine Beyond Bias and BarriersFulfilling the Potential of Women in Academic Science and Engineering. National Academy of Sciences, Washington, DC2007Google Scholar That was 6 yr ago and little has changed. In research, generally, there have been initiatives with regard to gender balance and there have been improvements in many areas. The Engender Project was launched a year ago, with the aim of documenting good practices which address equality in healthcare'both in terms of staffing and provision.26http://www.gender-summit.eu/ (accessed 20 November 2012).Google Scholar The gender dimension has been a major focus of science policy in the EU, and Horizon 2020 has recently been announced, an approach where EU funding for research and innovation is being brought together to reduce ‘red tape’, with the aims of promoting excellent science and innovation and ‘creating a better society’. This initiative aims to promote equality between men and women by ‘correcting the imbalances in the participation of female scientists at all stages of research careers’. How this is to be achieved is not stated. Women are not prominent in leadership roles in any discipline.27http://www.ted.com/talks/sheryl_sandberg_why_we_have_too_few_women_leaders.html (accessed 18 November 2012).Google Scholar 28Bebbington D Revisiting diversity in leadership.In Practice. 2012; 31: 1-4Google Scholar In business, the percentage of women on the boards of the top 100 companies listed on the London Stock Exchange (FTSE-100) is only 17.3%. The 30% Club25http://www.30percentclub.org.uk (accessed 18 February 2013).Google Scholar is a group of chairmen of corporate boards who are committed to increasing the representation of women on companies’ boards, and reinforces the concept that this is ‘a strategic issue, not a women's issue’. Institutions, whether businesses, universities or journals need policies such as mentoring schemes to ensure consistency in recruitment and provision of opportunities.28Bebbington D Revisiting diversity in leadership.In Practice. 2012; 31: 1-4Google Scholar Visible leadership on matters relating to equality and diversity are paramount, give credibility, and ensure that strategic and corporate plans actively consider and incorporate diversity'not just in relation to gender. Establishing reliable systems to record and monitor data is an essential first step. How can you put your house in order if you don't know how things are now? Our small survey of the gender of published authors in 2011 reveals what we already suspected'that most authors in the BJA are male. In future, the BJA plans to ask, as part of the submission process, whether submitting authors are male or female and ultimately asking reviewers the same question. This is the approach of Athena SWAN, a charter for higher education in the UK, which aims to advance the representation of women in science, engineering, and technology including medicine, recognizing the need for action from all levels of an organization, with strong commitment from those in leadership roles.29Athena SWAN Charter for Women in Science http://www.athenaswan.org.uk/content/athena-swan (accessed 22 November 2012).Google Scholar The ‘carrot’ is an award'bronze, silver, and gold'for differing levels of action, the first of which is to ‘identify the challenges and opportunities’—in other words get the data. There have only ever been two gold awards'for this a university department has to actually have results in terms of increasing women's career progression. The ‘stick’ came from the Chief Medical Officer Professor Dame Sally Davies who announced in 2011 that criteria for some major research funding streams are to be dependent on the applicant university having achieved an Athena SWAN Charter Silver Award for gender equality. Perhaps, it is time for proactive measures. Iceland has recently taken the step to legislate to ensure public companies meet the goal of a gender-equal composition of their boards by September 1, 2013. Iceland has the greatest equality between men and women, according to the World Economic Forum's Global Gender Gap Report.4Hausmann R Tyson LD Zahidi S The Global Gender Gap Report. 2011http://www3.weforum.org/docs/WEF_GenderGap_Report_2011.pdfGoogle Scholar Iceland is followed closely by the other Nordic countries, which have consistently held the highest positions in terms of Global Gender Gap index and are useful for international comparisons. The UK and the USA are currently level-pegging at 15th and 16th positions. These countries have attained gender parity at all levels of education, but gender equality in political empowerment, health and survival, and economic participation/opportunity still have some way to go, much like the BJA. Positive discrimination is something which many people are opposed to, but there are measures which can be undertaken which can be termed positive action. These fall short of the quota system mandated by Iceland but are likely to be effective. Table 1 shows suggestions based on the 30% Club's ‘How to balance your Board’—instructions which are applicable in every way to this journal.25http://www.30percentclub.org.uk (accessed 18 February 2013).Google ScholarTable 1How to balance your Board. Based on suggestions from the 30% Club: http://www.30percentclub.org.uk25http://www.30percentclub.org.uk (accessed 18 February 2013).Google Scholar •Raise awareness and commit•Identify and mentor promising individuals•Assess working practices, policies, culture, and barriers•Ensure processes encourage women to apply•Think laterally when considering nominations/applications•Ensure there are female candidates Open table in a new tab In terms of the BJA, current editorial board members must commit to a future editorial board which reflects our discipline and ensure that systems, policies, and culture do not put women off from getting involved. Positive action might be specifically targeting suitably qualified women as reviewers or editorial board members or asking current editorial board members to recommend a female academic to join the editorial board, or be a guest editor of a special edition. This should not be seen in any way demeaning to the women concerned. The prestige and respect which the BJA currently holds is at stake if we continue to have a non-representative editorial board as we do at present. H.F.G. instigated the study, conducted data analysis and drafted the paper. L.A.C. revised the paper and both authors agreed on the final version. H.F.G. and L.A.C. are editors of the British Journal of Anaesthesia and members of the editorial board. Both have received research funding from the BJA and both authors are female. The authors did not receive any specific funding for this study. Download .zip (.0 MB) Help with zip files Download .zip (.0 MB) Help with zip files Download .zip (.0 MB) Help with zip files