Abstract
Gender disparities can first be seen as the silent and invisible data gap. Caroline Criado Perez, the author of Invisible Women: Data Bias in a World Designed for Men, illuminates the sad fact that the lives and bodies of men have represented “humans” in science, the media, literature, and economics. 1 Earlier this year two women astronauts were scheduled to spacewalk together outside the International Space Station—a historical event: the first all-women's spacewalk. Instead, one of the women scheduled had to be replaced with a male colleague because the mission did not have two spacesuits appropriately designed for women to wear safely. This would have been a momentous occasion for these women who have dedicated their entire careers as astronauts but NASA had not considered their biological sex when designing the equipment. This equipment, and all of their equipment, was suitable for men, despite a well-promulgated understanding of the influence that sex and gender have on physiological needs of humans traveling in space. 2 Since then, astronauts Jessica Meir and Christina Koch made the 221st NASA spacewalk history as the first all women team. These events highlighted the enormous personal and historical consequences for these astronauts and for women everywhere on the importance of taking into account biological sex and sociocultural gender in society.
In this issue of the Journal of Women's Health, Dr. Lewiss and colleagues 3 draws attention to gender inequity in academic medicine, highlighting the barriers marginalizing these women and often render them invisible. Sadly, although this writing focuses on academic medicine, the issues it brings forth are broadly generalizable. Its text could be boilerplate for almost any piece defining gender inequity for women. Highly qualified women in academic medicine have been passed over and not given consideration for promotion, and leadership by (mostly male dominated) committees and boards. Women have also been disregarded for advancement in many other disciplines of science, research, and education.
Sadly, this inequity is a symptom of a much larger disease. This disease affects the women striving to achieve success but has many other victims as well.
I am mentoring a young woman who is applying to medical school. She is encouraged by the growing number of women enrolling in U.S. medical schools: women now represent 51.6% of matriculating medical school students. 4 If she matriculates, she will begin learning from evidence accumulated from research carried out primarily on men. This fact will unlikely be revealed to her. Her textbooks will have photographs of male figures as default anatomical models with female reproductive structures as add-ons. She will be tested on the symptoms of heart attacks and strokes as they present in men. She will be told that these manifestations are “typical” while women's symptoms are “atypical.” How atypical is a symptom if more than half the people presenting with the disease have it? She will learn the intricacies of electronic medical records and be forced to use a photo of a male thorax for her female patients with chest and abdominal pain. By that point she may be so inured to this deception that she will not notice it all. She and her female colleagues have begun their transformation to invisibility, a universal condition suffered by women in academics, women in our (still) male-dominated world.
This young woman may then transition to a career in which the subtle and not so subtle disparities and micro/macro inequities described by Dr. Lewiss and colleagues are palpable. Although women make up over half the population as a whole, account for over half of medical students, comprise >50% of the health care workforce, they remain underrepresented in every phase of academic medicine, from clinical trials to top health care leadership positions. Women have been excluded from the stewardship of medicine, and, as a result, the care they receive continues to be unequal or inadequate. This gender bias has led to inferior care for both men and women and to a waste of scarce medical resources. 5
Health Care Means Caring For All
The relationship of sex and gender with health outcomes remain largely neglected in the science literature. Of 10 drugs recently withdrawn from the U.S. market, 8 provoked severe and potentially fatal health risks for women. 6 Researchers must include women in preclinical and clinical research and must commit to sex- and gender-based analyses to avoid these tragic outcomes in the future. This approach is now supported by National Institutes of Health Policy on Sex as a Biological Variable 7 and the Sex and Gender Equity in Research Guidelines as promulgated by the International Committee of Medical Journal Editors ensuring that journal publications should include sex-based analysis. 8 These initiatives were designed to create new standards of quality and generalizability for evidence-based medicine.
New evidence supports the increased likelihood of appropriate sex- and gender-based analyses to the presence and number of women in the author group, especially when those women are in positions as first and last authors. Nielsen et al. came to this conclusion after reviewing >1.5 million research articles at which time they also noted a significant global gender disparity in authorship participation. 9 Women comprised 40% of first authors, 27% of last authors, and 35% of the authors overall per author group in disease-specific research.
It is essential that women achieve substantial participation at the highest levels of academic medicine—supporting and advancing mentorship, promotion, grantsmanship, and leadership and promoting sex- and gender-based data collection and analyses. Future efforts in crafting scientific guidelines and policies must advance this agenda that will have tremendous impact on academia, medicine, health, livelihood, and parity. If we do not make diversity and equity a priority, then the house of medicine will lack credibility and longevity.
From Gender Bias to Gender Awareness in Medical Education
There is no one-size-fits-all solution for unconscious gender bias. Creating awareness of gender differences and gender inequalities as determinants of health within medical education and practice will improve every aspect of the health care delivery system. The active engagement of men in discussing gender bias in medical education as well as the conscious and active advancement of leadership of senior academic women is crucial for progress. These women and men can engage with faculty members to raise awareness, create positive intervention, and facilitate change.
We, women and men in medicine, must work together to support, educate, and promote each other. Our mission as healers of patients and teachers of future generations of healers is sacred and now is the time to embrace the true and real perspective of equality to guide our way forward.