The Trouble with Girls: Obstacles to Women's Success in Medicine And

BMJ 2018;363:k5232 doi: 10.1136/bmj.k5232 (Published 13 December 2018) Page 1 of 4

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CHRISTMAS 2018: EQUAL TO THE TASK The trouble with girls: obstacles to women’s success in medicine and research—an essay by Laurie Garrett 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

Laurie Garrett journalist and author

New York, USA

I asked Google who discovered climate change, and its top appointments, extreme bias in research funding, access to journal answer was John Tyndall, who published evidence in 1859 on publication, and invitations to present at elite meetings. carbon dioxide heating the Earth’s surface. Early career access to education and But Google was incorrect. In 1848 Elizabeth Cady Stanton and Eunice Foote organized the first women’s rights conference, in appointments http://www.bmj.com/ Seneca Falls, New York. Afterwards, Foote, a scientist, This year Tokyo Medical University revealed that it had for measured the temperature of various gases when subjected to years manipulated women’s test scores and admissions solar radiation. Carbon dioxide became the hottest, and Foote rankings—by as much as 49 out of 100—to ensure that no sent her findings to the American Association for the woman had more than 80 points. Nearly 9% of male applicants Advancement of Science.1 won a place, but just 3% of women did so.2 Japan has one of It accepted her paper, but Foote, as a woman, was not allowed the world’s lowest female physician ratios, and just 21% of all to address the meeting, so her paper was read by a man. And doctor of medicine degrees were awarded to women in 2016. on 18 December 2018 by guest. Protected copyright. the association refused to publish a woman’s work in the Fewer female PhD recipients apply for US academic positions proceedings, so it was released separately. Foote’s work clearly overall,3 and the gap is wider in Europe. In a 2004 survey women preceded Tyndall’s, but her contribution to climate science is were awarded just 36% of science PhDs, 33% of junior faculty buried in obscurity. positions, and 11% of tenured senior faculty slots in Europe. In the 1900s the astrophysicist Jocelyn Bell Burnell’s male boss An international survey found that women in medical and received the Nobel Prize for proving the existence of pulsars. science academia were far less likely than male peers to become Rosalind Franklin died before she could contest the 1962 Nobel full or associate professors (60% of appropriately trained men Prize in Physiology or Medicine—awarded to James Watson, versus 31% of women).4 And women were more likely to fill Francis Crick, and her boss, Maurice Wilkins. Franklin’s x ray lower status academic slots: “researcher,” assistant professor, crystallography was used, without her consent, by Watson and or adjunct teaching positions (about 38% of men in total versus Crick to decipher DNA’s double helix. And, in 2018, Donna 63% of women). In US medical schools “women make up 38% Strickland became only the third female honored with a physics of faculty members, 21% of full professors, and 15% of Nobel Prize, raising the total of all female science Nobelists department chairs”—despite near parity among younger ever to 3%. Only then did Canada’s University of Waterloo physicians and medical students.5 make her a full professor. Once working, female researchers face huge financial bias: a These stories illustrate the barriers experienced by women at US survey found that the average graduate student stipend was the top of scientific and medical achievement. But most women $30 500 (£24 150; €26750) for men but $26 500 for women.6 pursuing research in these disciplines encounter hurdles far In the UK female scientists earn 20% less a year than men on earlier in their careers. average, and they tend to earn less from the start.7 Sex bias hampers female advancement in medicine and science in four key ways: access to advanced education and

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The trouble with girls a similar gap,19 largely reflecting the greater likelihood that men fill top management positions and that women fill most low BMJ: first published as 10.1136/bmj.k5232 on 13 December 2018. Downloaded from Women who pursue biomedical and other science careers face prestige and clerical posts. biases that men never experience. Consider the 2015 speech by In research, pay gaps may reflect difficulty in winning grants the British Nobel laureate Tim Hunt about “my trouble with from funders such as the UK Wellcome Trust and the US girls. Three things happen when they are in the lab,” he said in National Institutes of Health (NIH).20 In 2012, for example, just a speech. “You fall in love with them, they fall in love with you, 30% of NIH grants went to female principal investigators.21 and when you criticize them they cry.”8 Worse, these women got smaller grants, with 2012 averages of University College London forced Hunt’s resignation, but these $507 279 for men and $421 385 for women—a gap of nearly views are hardly rare in medicine and science. This September $86 000. The gap is also wide at the Wellcome Trust, where Gary Tigges, a Texan physician, wrote in the Dallas Medical female principal investigators received an average £44 735 less Journal that female doctors should be paid less: “Female than men in 2000-08.22 physicians do not work as hard and do not see as many patients However, when review committees were blinded to the names as male physicians. This is because they choose to, or they (and sex) of principal investigators, they awarded far more, and simply don’t want to be rushed, or they don’t want to work the larger, grants to women. Wellcome explained that this was long hours.”9 “attributable to less favorable assessments of women as principal Sex bias exists even in disciplines that are overwhelmingly investigators, not differences in assessments of the quality of female in number, such as gynecology, public health, and science led by women.”23 nursing. Over 80% of global health undergraduates in the US Wellcome says that it is committed to achieving equity by 2023, are female, as are 70% of medical students who hope to engage but it has a long way to go. Men hold nine in 12 top management in global health.10 Yet just 39% of their faculty, and 24% of positions, and only 23% of grant panel members are women. directors of the global health programs they might one day work The NIH also says that it wants equity, but the proportion of with, are women. A 2018 US survey of nursing—arguably the grants awarded to women in nearly every category has not most female field in health—found that men averaged $79 688 budged since 1998.24 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 Access to journal publication: “publish or perish” Two thirds of women have been harassed Careers are made or broken on rates of publication in journals, The US National Academies of Sciences found this year, in an a journal’s prestige, and how frequently an author’s work is extensive assessment of bias in medicine and the sciences, that cited. From 1994 to 2014 the number of papers with a female http://www.bmj.com/ a third of women had experienced gender harassment, and a first author jumped 37%,25 but actual publication rates plateaued further fifth had also experienced unwanted sexual attention.12 well below those of men.26 Just a third of women had never experienced such odious This year Nature reviewed its own performance: “Manuscripts affronts. from female authors . . . are accepted with a lower rate than Female medical students were the most likely to have been those from male authors.”27 The 10 Lancet journals also found mistreated: 63% had been subjected to gender harassment or that none approached gender parity in publishing female first sexual assault and demands. The academies found that or last authored papers: overall, about a third of papers have a harassment is corrosive, generally forcing victimized women female primary author.28 And Science found a similar distribution on 18 December 2018 by guest. Protected copyright. to flee institutions—and even their careers. Four factors make in its publications.29 medicine and the sciences especially vulnerable to harassment: In Nature only a third of solicited editorials and commentaries intimate reliance on mentors; a meritocracy that penalizes were female authored in 2017, up from 19% a decade absence from work for any reason, including harassment; an previously.30 A similar increase has occurred at the Lancet, often “macho” culture; and rumormongering in most where in 2018 a third of commissioned papers were female institutions.13 authored, says its executive editor, Jocalyn Clark. Especially worrisome are allegations of institutional protection Peer reviewers perhaps hold the real power: at Nature 80% of of accused abusers, including at institutions founded on these were male in 2017. None of the most influential medical principles of human rights, such as UNAIDS. An independent or science journals has female reviewer representation above review panel concluded that “The UNAIDS Secretariat is in 28%, and most are closer to just 17%, says Clark. The male crisis . . . leaders, policies and processes . . . failed to prevent domination of the process reflects who is invited, not a higher or properly respond to allegations of harassment including sexual refusal rate by women.23 harassment, bullying and abuse of power . . . the evidence . . . 14 is overwhelming.” Not invited to present at elite meetings Scrutiny of harassment can backfire. In a recent survey of 3000 male medical leaders three quarters reported being afraid of Careers also depend on addressing major medical and scientific being labelled a harasser, and most refused to meet alone with meetings. Here, too, bias is so evident that the Oxford English women.15 Dictionary has defined a new word: the “manel.” These all male panels are causing outrage. Extreme bias in research funding Recently, the annual meeting of the International Federation of Gynecology and Obstetrics opened with a panel of nine men The gender pay gap among doctors remains startling,16 regardless and one woman. The 2014 Global Summit of Women opened of specialty.17 One report found that US women in 2017 earned in Paris with a panel of six men. Brigham Young University’s $105 000 less than men on average, worse than the 2016 pay “Women in Math” meeting featured four speakers, all male. gap of $91 284.18 A 2018 BMJ survey of NHS employees found

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And this year’s Global Health Summit in Berlin was widely services and laboratories, will thrive if they stop penalizing mocked for including several all male panels. women for childbirth and reward men for time spent with family. BMJ: first published as 10.1136/bmj.k5232 on 13 December 2018. Downloaded from An analysis of speakers at the top four annual virology In 1856, Eunice Foote had to listen to a man present her paper conferences concluded that, at the current rate of “improvement” because of her sex. In 2019, women undoubtedly have greater in the number of female speakers invited, it “may take decades access to academic training, support, and mentorship than in to reach parity” without “sustained effort.”31 A survey of 3652 the mid-19th century. But the ultimate and fundamental sex speakers invited to address major universities in 2013-14 found equality that Foote and her colleagues called for in 1848 has clear bias in every category and concluded, “Women don’t yet to be achieved in medicine, nursing, public health, and the choose not to talk. They simply aren’t invited to do so as often sciences. as they should be.”32 Biography Recognizing the childbirth bias Laurie Garrett is a Pulitzer Prize winning science writer, author, and foreign policy analyst, most recently with the Council on Foreign Relations. She is One factor above all others is key to these obstacles: childbirth. founder of the Anthropos Initiative, a New York based program working at the interface of climate change and human health. The material herein presented Ages 21 to 35, the most critical for career development, are is based on her invited presentation to the Women Leaders in Global Health precisely when women are most likely to start a family.33 Conference, sponsored by the London School of Hygiene and Tropical Medicine in London in November 2018. 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 I thank Lauren Wedekind, a graduate student at Oxford University, who helped well have soared ahead, leaving her behind in a lower paying, research the speech that gave rise to this report. less prestigious role. Competing interests: I have read and understood BMJ policy on declaration of When most Western women reach a career/children juncture in interests and have no relevant interests to declare. their late 20s their choices tend to reflect those their mothers made a generation earlier.34 Although men and women view Provenance and peer review: Commissioned; not externally peer reviewed. their careers as equally attainable, women seem to place far 1 Mitchell J. Righting a scientific wrong. Current 2018. www.news.ucsb.edu/2018/018985/ more weight on “life goals.” Overall, women find power “less righting-scientific-wrong. desirable” than family and lifestyle.35 2 Takezawa S. Japan university admits altering test scores to keep women out. Bloomberg 7 Aug 2018. https://bloom.bg/2GaovZP. In recognition of this childbirth bias, some grant making 3 National Research Council. Gender differences at critical transitions in the careers of agencies are beginning to consider the time and energy that science, engineering, and mathematics faculty. National Academies Press, 2010. 10.17226/12062. prospective grantees invest in rearing a family. Recently, for 4 van den Besselaar P, Sandström U. Gender differences in research performance and its example, the NIH announced that it would automatically extend impact on careers: a longitudinal case study. Scientometrics 2016;106:143-62.

10.1007/s11192-015-1775-3. 26798162 http://www.bmj.com/ “early stage investigator” status, allowing researchers to apply 5 Silver JK. Ethical leaders: use science to advance gender equity in medicine. Stat 2018. for additional support without penalties if the scientist gives https://www.statnews.com/2018/11/13/use-science-advance-gender-equity-medicine/. 6 Moss-Racusin CA, Dovidio JF, Brescoll VL, Graham MJ, Handelsman J. Science faculty’s birth during her grant period. subtle gender biases favor male students. Proc Natl Acad Sci U S A 2012;109:16474-9. A host of organizations have sprung up to battle manels and 10.1073/pnas.1211286109 22988126 7 Fleming N. How the gender pay gap permeates science and engineering. New Scientist other forms of bias, including 500 Women Scientists, Gender 2018. https://www.newscientist.com/article/mg23731670-100-how-the-gender-pay-gap- Avenger, and women’s caucuses within the UN. Professional permeates-science-and-engineering. 8 Sir Tim Hunt resigns from university role in girls comment. BBC News 11 June 2015. societies for journal editors have passed resolutions aimed at https://www.bbc.com/news/uk-33090022. fighting bias in publishing, although little has come of them in 9 Ramierez M. “Female physicians do not work as hard,” Plano doctor tells Dallas Medical on 18 December 2018 by guest. Protected copyright. Journal. Dallas News 2 Sept 2018. https://www.dallasnews.com/news/plano/2018/09/01/ practice. Women Leaders in Global Health, formed in 2017, female-physicians-not-work-hard-plano-doctor-tells-dallas-medical-journal. has held two international meetings to explore how to increase 10 Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Acad Med 2014;89:1103-7. 10.1097/ACM.0000000000000369 24918761 female clout. 11 Michek K. Nurses not immune to gender wage gap. HealthLeaders 20 June 2018. https: The German Cancer Research Center has taken perhaps the //www.healthleadersmedia.com/nursing/nurses-not-immune-gender-wage-gap. 12 National Academies of Sciences, Engineering, and Medicine. Sexual harassment of biggest step: this year it hid the identities of all authors who women: climate, culture, and consequences in academic sciences, engineering, and applied to speak at its conference, leaving only one basis for medicine. National Academies Press, 2018. 10.17226/24994. 13 Batty D, Davis N. Why science breeds a culture of sexism. Guardian 7 July 2018. https:/ judging entries: the merit of the work. The result? A whopping /www.theguardian.com/science/2018/jul/07/why-science-is-breeding-ground-for-sexism? 82% of invited speakers at the October gathering were women.36 CMP=Share_iOSApp_Other. 14 Report on the work of the Independent Expert Panel on prevention of and response to As women fill a greater number of science, medicine, harassment, including sexual harassment; bullying and abuse of power at UNAIDS biotechnology, and engineering posts their value to the Secretariat. 7 Dec 2018. http://www.unaids.org/en/resources/documents/2018/report-iep. 15 Zillman C. A new poll on sexual harassment suggests why “Me Too” went so insanely disciplines becomes obvious. But this does not inevitably lead viral. Fortune 17 October 2017. http://fortune.com/2017/10/17/me-too-hashtag-sexual- to improvements in the balance of power, prestige, and pay—as harassment-at-work-stats. 16 Mukherjee S. Here’s how much less women and black doctors make than their white male the examples from nursing, public health, and many medical colleagues. Fortune 11 May 2018. http://fortune.com/2018/04/11/doctor-pay-gap-gender- specialties show. Pay equity, publication, and power aren’t race/. 17 Grover N. Male doctors make a lot more in industry payments than their female peers. simply given: they must be fought for and defended. The Reuters 27 Dec 2017. https://www.reuters.com/article/us-health-physicians-gender-gap/ positive initiatives at national academies, the NIH, Wellcome, male-doctors-make-a-lot-more-in-industry-payments-than-female-peers-idUSKBN1EL1DZ. and key publications must be backed by ongoing pressure from 18 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 the medical and scientific communities. In all disciplines, 2018. https://blog.doximity.com/articles/doximity-2018-physician-compensation-report. including those with proportionally few women, manels should 19 Appleby J. The gender pay gap in the NHS. BMJ 2018;361:k154110.1136/bmj.k1541. 20 National Institutes of Health. NIH data book 2018. http://report.nih.gov/ndb/index.aspx. be denounced and considered disgraceful. 21 Ley TJ, Hamilton BH. Sociology. The gender gap in NIH grant applications. Science 2008;322:1472-4. 10.1126/science.1165878. 19056961 It is not in any society’s interests to pit the value of education 22 Bedi G, Van Dam NT, Munafo M. Gender inequality in awarded research grants. Lancet and training against family: both are necessary. It makes no 2012;380:474. 10.1016/S0140-6736(12)61292-6. 22863053 23 Witteman HO, Hendricks M, Straus S, Tannenbaum C. Female grant applicants are sense to invest in training smart women only to snatch their equally successful when peer reviewers assess the science, but not when they assess advancement away because they bear and raise babies. All the scientist. 2017. 10.1101/232868. institutions, from universities and research funders to health

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