Sunday, 16 December 2018

The trouble with girls: obstacles to women’s success in medicine and research—an essay by Laurie Garrett

Feature Christmas 2018: Equal to the Task BMJ 2018; 363 doi: (Published 13 December 2018) Cite this as: BMJ 2018;363:k5232 Article Related content Metrics Responses Laurie Garrett, journalist and author Author affiliations Female medical practitioners and researchers face specific disadvantages in four key areas, writes Laurie Garrett. Childbirth is a common factor, and institutions and funders urgently need to recognize and respond to this I asked Google who discovered climate change, and its top answer was John Tyndall, who published evidence in 1859 on carbon dioxide heating the Earth’s surface. But Google was incorrect. In 1848 Elizabeth Cady Stanton and Eunice Foote organized the first women’s rights conference, in Seneca Falls, New York. Afterwards, Foote, a scientist, measured the temperature of various gases when subjected to solar radiation. Carbon dioxide became the hottest, and Foote sent her findings to the American Association for the Advancement of Science.1 It accepted her paper, but Foote, as a woman, was not allowed to address the meeting, so her paper was read by a man. And the association refused to publish a woman’s work in the proceedings, so it was released separately. Foote’s work clearly preceded Tyndall’s, but her contribution to climate science is buried in obscurity. In the 1900s the astrophysicist Jocelyn Bell Burnell’s male boss received the Nobel Prize for proving the existence of pulsars. Rosalind Franklin died before she could contest the 1962 Nobel Prize in Physiology or Medicine—awarded to James Watson, Francis Crick, and her boss, Maurice Wilkins. Franklin’s x ray crystallography was used, without her consent, by Watson and Crick to decipher DNA’s double helix. And, in 2018, Donna Strickland became only the third female honored with a physics Nobel Prize, raising the total of all female science Nobelists ever to 3%. Only then did Canada’s University of Waterloo make her a full professor. These stories illustrate the barriers experienced by women at the top of scientific and medical achievement. But most women pursuing research in these disciplines encounter hurdles far earlier in their careers. Sex bias hampers female advancement in medicine and science in four key ways: access to advanced education and appointments, extreme bias in research funding, access to journal publication, and invitations to present at elite meetings. Early career access to education and appointments This year Tokyo Medical University revealed that it had for years manipulated women’s test scores and admissions rankings—by as much as 49 out of 100—to ensure that no woman had more than 80 points. Nearly 9% of male applicants won a place, but just 3% of women did so.2 Japan has one of the world’s lowest female physician ratios, and just 21% of all doctor of medicine degrees were awarded to women in 2016. Fewer female PhD recipients apply for US academic positions overall,3 and the gap is wider in Europe. In a 2004 survey women were awarded just 36% of science PhDs, 33% of junior faculty positions, and 11% of tenured senior faculty slots in Europe. An international survey found that women in medical and science academia were far less likely than male peers to become full or associate professors (60% of appropriately trained men versus 31% of women).4 And women were more likely to fill lower status academic slots: “researcher,” assistant professor, or adjunct teaching positions (about 38% of men in total versus 63% of women). In US medical schools “women make up 38% of faculty members, 21% of full professors, and 15% of department chairs”—despite near parity among younger physicians and medical students.5 Once working, female researchers face huge financial bias: a US survey found that the average graduate student stipend was $30 500 (£24 150; €26750) for men but $26 500 for women.6 In the UK female scientists earn 20% less a year than men on average, and they tend to earn less from the start.7 The trouble with girls Women who pursue biomedical and other science careers face biases that men never experience. Consider the 2015 speech by the British Nobel laureate Tim Hunt about “my trouble with girls. Three things happen when they are in the lab,” he said in a speech. “You fall in love with them, they fall in love with you, and when you criticize them they cry.”8 University College London forced Hunt’s resignation, but these views are hardly rare in medicine and science. This September Gary Tigges, a Texan physician, wrote in the Dallas Medical Journal that female doctors should be paid less: “Female physicians do not work as hard and do not see as many patients as male physicians. This is because they choose to, or they simply don’t want to be rushed, or they don’t want to work the long hours.”9 Sex bias exists even in disciplines that are overwhelmingly female in number, such as gynecology, public health, and nursing. Over 80% of global health undergraduates in the US are female, as are 70% of medical students who hope to engage in global health.10 Yet just 39% of their faculty, and 24% of directors of the global health programs they might one day work with, are women. A 2018 US survey of nursing—arguably the most female field in health—found that men averaged $79 688 salaries, $6598 more than their female peers. Those who rose to become chief nursing officers averaged $132 700 if male and $127 047 if female.11 Two thirds of women have been harassed The US National Academies of Sciences found this year, in an extensive assessment of bias in medicine and the sciences, that a third of women had experienced gender harassment, and a further fifth had also experienced unwanted sexual attention.12 Just a third of women had never experienced such odious affronts. Female medical students were the most likely to have been mistreated: 63% had been subjected to gender harassment or sexual assault and demands. The academies found that harassment is corrosive, generally forcing victimized women to flee institutions—and even their careers. Four factors make medicine and the sciences especially vulnerable to harassment: intimate reliance on mentors; a meritocracy that penalizes absence from work for any reason, including harassment; an often “macho” culture; and rumormongering in most institutions.13 Especially worrisome are allegations of institutional protection of accused abusers, including at institutions founded on principles of human rights, such as UNAIDS. An independent review panel concluded that “The UNAIDS Secretariat is in crisis . . . leaders, policies and processes . . . failed to prevent or properly respond to allegations of harassment including sexual harassment, bullying and abuse of power . . . the evidence . . . is overwhelming.”14 Scrutiny of harassment can backfire. In a recent survey of 3000 male medical leaders three quarters reported being afraid of being labelled a harasser, and most refused to meet alone with women.15 Extreme bias in research funding The gender pay gap among doctors remains startling,16 regardless of specialty.17 One report found that US women in 2017 earned $105 000 less than men on average, worse than the 2016 pay gap of $91 284.18 A 2018 BMJ survey of NHS employees found a similar gap,19 largely reflecting the greater likelihood that men fill top management positions and that women fill most low prestige and clerical posts. In research, pay gaps may reflect difficulty in winning grants from funders such as the UK Wellcome Trust and the US National Institutes of Health (NIH).20 In 2012, for example, just 30% of NIH grants went to female principal investigators.21 Worse, these women got smaller grants, with 2012 averages of $507 279 for men and $421 385 for women—a gap of nearly $86 000. The gap is also wide at the Wellcome Trust, where female principal investigators received an average £44 735 less than men in 2000-08.22 However, when review committees were blinded to the names (and sex) of principal investigators, they awarded far more, and larger, grants to women. Wellcome explained that this was “attributable to less favorable assessments of women as principal investigators, not differences in assessments of the quality of science led by women.”23 Wellcome says that it is committed to achieving equity by 2023, but it has a long way to go. Men hold nine in 12 top management positions, and only 23% of grant panel members are women. The NIH also says that it wants equity, but the proportion of grants awarded to women in nearly every category has not budged since 1998.24 Access to journal publication: “publish or perish” Careers are made or broken on rates of publication in journals, a journal’s prestige, and how frequently an author’s work is cited. From 1994 to 2014 the number of papers with a female first author jumped 37%,25 but actual publication rates plateaued well below those of men.26 This year Nature reviewed its own performance: “Manuscripts from female authors . . . are accepted with a lower rate than those from male authors.”27 The 10 Lancet journals also found that none approached gender parity in publishing female first or last authored papers: overall, about a third of papers have a female primary author.28 And Science found a similar distribution in its publications.29 In Nature only a third of solicited editorials and commentaries were female authored in 2017, up from 19% a decade previously.30 A similar increase has occurred at the Lancet, where in 2018 a third of commissioned papers were female authored, says its executive editor, Jocalyn Clark. Peer reviewers perhaps hold the real power: at Nature 80% of these were male in 2017. None of the most influential medical or science journals has female reviewer representation above 28%, and most are closer to just 17%, says Clark. The male domination of the process reflects who is invited, not a higher refusal rate by women.23 Not invited to present at elite meetings Careers also depend on addressing major medical and scientific meetings. Here, too, bias is so evident that the Oxford English Dictionary has defined a new word: the “manel.” These all male panels are causing outrage. Recently, the annual meeting of the International Federation of Gynecology and Obstetrics opened with a panel of nine men and one woman. The 2014 Global Summit of Women opened in Paris with a panel of six men. Brigham Young University’s “Women in Math” meeting featured four speakers, all male. And this year’s Global Health Summit in Berlin was widely mocked for including several all male panels. An analysis of speakers at the top four annual virology conferences concluded that, at the current rate of “improvement” in the number of female speakers invited, it “may take decades to reach parity” without “sustained effort.”31 A survey of 3652 speakers invited to address major universities in 2013-14 found clear bias in every category and concluded, “Women don’t choose not to talk. They simply aren’t invited to do so as often as they should be.”32 Recognizing the childbirth bias One factor above all others is key to these obstacles: childbirth. Ages 21 to 35, the most critical for career development, are precisely when women are most likely to start a family.33 With each birth, a woman takes time off from work while her male peers move ahead. By the time a woman has had three children, the men who finished medical school with her may well have soared ahead, leaving her behind in a lower paying, less prestigious role. When most Western women reach a career/children juncture in their late 20s their choices tend to reflect those their mothers made a generation earlier.34 Although men and women view their careers as equally attainable, women seem to place far more weight on “life goals.” Overall, women find power “less desirable” than family and lifestyle.35 In recognition of this childbirth bias, some grant making agencies are beginning to consider the time and energy that prospective grantees invest in rearing a family. Recently, for example, the NIH announced that it would automatically extend “early stage investigator” status, allowing researchers to apply for additional support without penalties if the scientist gives birth during her grant period. A host of organizations have sprung up to battle manels and other forms of bias, including 500 Women Scientists, Gender Avenger, and women’s caucuses within the UN. Professional societies for journal editors have passed resolutions aimed at fighting bias in publishing, although little has come of them in practice. Women Leaders in Global Health, formed in 2017, has held two international meetings to explore how to increase female clout. The German Cancer Research Center has taken perhaps the biggest step: this year it hid the identities of all authors who applied to speak at its conference, leaving only one basis for judging entries: the merit of the work. The result? A whopping 82% of invited speakers at the October gathering were women.36 As women fill a greater number of science, medicine, biotechnology, and engineering posts their value to the disciplines becomes obvious. But this does not inevitably lead to improvements in the balance of power, prestige, and pay—as the examples from nursing, public health, and many medical specialties show. Pay equity, publication, and power aren’t simply given: they must be fought for and defended. The positive initiatives at national academies, the NIH, Wellcome, and key publications must be backed by ongoing pressure from the medical and scientific communities. In all disciplines, including those with proportionally few women, manels should be denounced and considered disgraceful. It is not in any society’s interests to pit the value of education and training against family: both are necessary. It makes no sense to invest in training smart women only to snatch their advancement away because they bear and raise babies. All institutions, from universities and research funders to health services and laboratories, will thrive if they stop penalizing women for childbirth and reward men for time spent with family. In 1856, Eunice Foote had to listen to a man present her paper because of her sex. In 2019, women undoubtedly have greater access to academic training, support, and mentorship than in the mid-19th century. But the ultimate and fundamental sex equality that Foote and her colleagues called for in 1848 has yet to be achieved in medicine, nursing, public health, and the sciences. Biography Laurie Garrett is a Pulitzer Prize winning science writer, author, and foreign policy analyst, most recently with the Council on Foreign Relations. She is founder of the Anthropos Initiative, a New York based program working at the interface of climate change and human health. The material herein presented is based on her invited presentation to the Women Leaders in Global Health Conference, sponsored by the London School of Hygiene and Tropical Medicine in London in November 2018. Acknowledgments I thank Lauren Wedekind, a graduate student at Oxford University, who helped research the speech that gave rise to this report. Footnotes Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; not externally peer reviewed. References ↵Mitchell J. Righting a scientific wrong. Current2018. Scholar ↵Takezawa S. Japan university admits altering test scores to keep women out. Bloomberg 7 Aug 2018. Scholar ↵National Research Council. Gender differences at critical transitions in the careers of science, engineering, and mathematics faculty.National Academies Press, 2010. doi:10.17226/12062.CrossRefGoogle Scholar ↵van den Besselaar P, Sandström U. Gender differences in research performance and its impact on careers: a longitudinal case study. Scientometrics2016;106:143-62. doi:10.1007/s11192-015-1775-3. pmid:26798162CrossRefPubMedGoogle Scholar ↵Silver JK. Ethical leaders: use science to advance gender equity in medicine. Stat2018. Scholar ↵Moss-Racusin CA, Dovidio JF, Brescoll VL, Graham MJ, Handelsman J. Science faculty’s subtle gender biases favor male students. Proc Natl Acad Sci U S A2012;109:16474-9. doi:10.1073/pnas.1211286109 pmid:22988126Abstract/FREE Full TextGoogle Scholar ↵Fleming N. How the gender pay gap permeates science and engineering. New Scientist 2018. Scholar ↵Sir Tim Hunt resigns from university role in girls comment. BBC News 11 June 2015. Scholar ↵Ramierez M. “Female physicians do not work as hard,” Plano doctor tells Dallas Medical Journal. Dallas News 2 Sept 2018. Scholar ↵Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Acad Med2014;89:1103-7. doi:10.1097/ACM.0000000000000369 pmid:24918761CrossRefPubMedGoogle Scholar ↵Michek K. Nurses not immune to gender wage gap. HealthLeaders 20 June 2018. Scholar ↵National Academies of Sciences, Engineering, and Medicine. Sexual harassment of women: climate, culture, and consequences in academic sciences, engineering, and medicine. National Academies Press, 2018. doi:10.17226/24994.CrossRefGoogle Scholar ↵Batty D, Davis N. Why science breeds a culture of sexism. Guardian 7 July 2018. Scholar ↵Report on the work of the Independent Expert Panel on prevention of and response to harassment, including sexual harassment; bullying and abuse of power at UNAIDS Secretariat. 7 Dec 2018. Scholar ↵Zillman C. A new poll on sexual harassment suggests why “Me Too” went so insanely viral. Fortune 17 October 2017. Scholar ↵Mukherjee S. Here’s how much less women and black doctors make than their white male colleagues. Fortune 11 May 2018. Scholar ↵Grover N. Male doctors make a lot more in industry payments than their female peers. Reuters 27 Dec 2017. Scholar ↵Doximity. Doximity 2018 physician compensation report: 65 000 US physicians from over 40 different specialties contributed to this year’s report. Here’s what we found. 27 March 2018. Scholar ↵Appleby J. The gender pay gap in the NHS. BMJ2018;361:k1541doi:10.1136/bmj.k1541.FREE Full TextGoogle Scholar ↵National Institutes of Health. NIH data book 2018. Scholar ↵Ley TJ, Hamilton BH. Sociology. The gender gap in NIH grant applications. Science2008;322:1472-4. doi:10.1126/science.1165878. pmid:19056961Abstract/FREE Full TextGoogle Scholar ↵Bedi G, Van Dam NT, Munafo M. Gender inequality in awarded research grants. Lancet2012;380:474. doi:10.1016/S0140-6736(12)61292-6. pmid:22863053CrossRefPubMedGoogle Scholar ↵Witteman HO, Hendricks M, Straus S, Tannenbaum C. Female grant applicants are equally successful when peer reviewers assess the science, but not when they assess the scientist. 2017. doi:10.1101/232868.Abstract/FREE Full TextGoogle Scholar ↵Hechtman LA, Moore NP, Schulkey CE, et al. NIH funding longevity by gender. Proc Natl Acad Sci U S A2018;115:7943-8. doi:10.1073/pnas.1800615115. pmid:30012615Abstract/FREE Full TextGoogle Scholar ↵Gender gap in medical journal first authorship, new research reveals. ScienceDaily 3 March 2016. Scholar ↵Bendels MHK, Müller R, Brueggmann D, Groneberg DA. Gender disparities in high-quality research revealed by Nature Index journals.PLOS, 2018, doi:10.1371/journal.pone.0189136.CrossRefGoogle Scholar ↵Editorial: gender imbalance in science journals is still pervasive. Nature2017;541:435-6. doi:10.1038/541435b.CrossRefGoogle Scholar ↵Gonzalez-Alvarez J. Author gender in the Lancet journals. 30 June 2018. doi:10.1016/S0140-6736(18)31139-5.Google Scholar ↵Berg J. Looking inward at gender issues. Science2017;355:329. doi:10.1126/science.aam8109. pmid:28126758Abstract/FREE Full TextGoogle Scholar ↵McGillivray B, De Ranieri E. Uptake and outcome of manuscripts in Nature journals by review model and author characteristics. Res Integr Peer Rev2018;3:5. doi:10.1186/s41073-018-0049-z. pmid:30140448CrossRefPubMedGoogle Scholar ↵Kalejta RF, Palmenberg AC. Gender parity trends for invited speakers at four prominent virology conference series. J Virol2017;91:e00739-17. doi:10.1128/JVI.00739-17. pmid:28592542CrossRefPubMedGoogle Scholar ↵Valian V. Two Nobels for women - why so slow?Nature2018;562:165. doi:10.1038/d41586-018-06953-6 pmid:30301999CrossRefPubMedGoogle Scholar ↵Ceci SJ, Williams WM. Understanding current causes of women’s underrepresentation in science. Proc Natl Acad Sci U S A2011;108:3157-62. doi:10.1073/pnas.1014871108. pmid:21300892Abstract/FREE Full TextGoogle Scholar ↵The roots of the gender pay gap lie in childhood. Women follow in their mothers’ footsteps when choosing whether to scale back their careers after having children. Economist2018. Scholar ↵Gino F, Wilmuth CA, Brooks AW. Gendered views of professional advancement. Proc Natl Acad Sci USA2015;112:12354-9. doi:10.1073/pnas.1502567112. pmid:26392533Abstract/FREE Full TextGoogle Scholar ↵Frontiers in Cancer Research. Scholar View Abstract