Gender Parity in Authorship of Gastroenterology Publications: Some Way yet Over the Horizon

Abstract

It is poignant that as the Trump administration in the United States dials back on policies effecting diversity, equity, and inclusion (DEI) [1], this issue of the journal carries a paper by Ng et al. that examined gender disparity in the authorship of Gastroenterology Clinical Practice Guidelines in the United States [2]. The key finding was that in 2019–2022, men outnumbered women as first authors of guidelines by 3 to 1, and as senior authors by more than 5 to 1. Even more telling was that when compared to retired guidelines on the same topics, female author representation had not improved between 2010 and 2020. Furthermore, the overwhelming majority of male first and senior authors held the faculty rank of professor in stark contrast to female authors among whom only a minority were professors. A marginally brighter picture emerged when the authorship of articles cited in the guidelines was analyzed. Between 1980 and 2020, there was an increase in the number of cited articles with women as first and senior authors, perhaps simply a reflection of the overall proliferation of research publications over time. However, while women still constituted a minority of first and senior authors, there was an encouraging increase in female representation over the period. A closer look at the data on cited articles gives more insight into the publication landscape. Women were even more underrepresented as first or senior authors in cited articles that were randomized controlled trials, systemic reviews or meta-analyses than of articles that were observational studies. As an extension of that, cited articles of which women were first or senior authors were much less likely to support a strong recommendation than articles authored by men. First and senior female authors of cited articles were again substantially less likely to hold the faculty rank of professor than their male counterparts.

While a similar study in the Asia Pacific region has not been conducted, it is more than likely that the gender disparity would be even more pronounced. There is already data showing that female participation as speakers, chairpersons, and organizing committee members of gastroenterology, hepatology, and endoscopy conferences in Asia is low [3].

Twenty-five years after the turn of the century, it seems anachronistic to have to argue the case for greater participation of women. Sadly, the lack of progress in many parts of the world and indeed regression in some parts, makes it important to revisit some of the arguments for greater female involvement. Moral and ethical considerations aside, there is compelling evidence from the business world that greater gender diversity among company leadership teams is associated with higher performance [4]. A recent study showed that patients treated by female physicians had lower mortality and readmission rates, an effect even more noticeable among female patients [5]. Female doctors at least in some contexts engage more in patient centered communication than their male counterparts [6]. Many women prefer their colonoscopies to be undertaken by female gastroenterologists [7].

The findings of Ng et al. [2] clearly reflect an underrepresentation of women in academic gastroenterology. The obvious question is why this is so. One intuitive explanation must be that women are underrepresented in the field of gastroenterology in general, resulting in a smaller pool to draw from. Despite a trend towards female medical students outnumbering males [8-10], women remain significantly underrepresented in both academic and non-academic gastroenterology [11, 12].

There appear to be three broad reasons for this. The first relates to barriers to women entering gastroenterology training. The second surrounds obstacles to equitable career progression within the profession, and the third to inequitable research funding and networking opportunities that are necessary for advancement in academia.

Considerations surrounding pregnancy and motherhood are key factors that appear to discourage women from entering gastroenterology training programs [13, 14]. Women entering demanding training programs must grapple with the dilemma of choosing between starting a family and completing their training in the stipulated time frame. Many women perceive a lack of support and encouragement from trainers and senior colleagues in what remains a male dominated specialty [14]. Gender differences in confidence and self-advocacy particularly with regards to procedural skills may contribute to the lower entry of women into gastroenterology fellowship programs [13]. The phenomenon of “imposter syndrome” that describes an attitude of doubting one's skills and successes seems to afflict women more than men. The ergonomics of endoscopic equipment that is likely to have been designed without much consideration of gender differences poses an additional challenge.

The challenge for many women of juggling family and career continues after training and into their fledgling careers. Many women gastroenterologists feel that pervasive gender bias impedes promotion and salary negotiations [14]. Success in academic careers is dependent on research output that is tied to success in obtaining grants and awards. Currently, the male female ratio of research fund recipients is heavily in favor of men. This could primarily be due to fewer female applicants rather than an intrinsic gender bias in the awarding process as suggested in one systematic review [15]. Across the world, women constitute a small minority of senior faculty, contributing to gender disparity in publication output. The fact that female first and senior authors of cited articles are less likely to hold the rank of professor than their male counterparts is circumstantial evidence that gender discrimination may be entrenched in the system.

In the long term and on a global level, redressing inequities require sociocultural changes in attitudes and societal reforms that encompass redefining gender roles in society. There are however pragmatic steps that can be taken immediately. For a start, it is important to recognize and acknowledge that inequity exists, is abhorrent and merits remedial measures. Advocacy groups such as WIGNAP (Women in Gastroenterology Network Asia-Pacific) have been leading the charge for some years by creating awareness and having a presence in national, regional and global discourse. A direct consequence of these efforts has been the recognition of the importance of women role models and mentors in both academic and non-academic gastroenterology. This has spawned an increasing willingness of established female gastroenterologists to take on that role. It has also enlightened senior male colleagues on the importance of sponsorship in giving female gastroenterologists increased visibility on various platforms. Task forces such as the Women-in-GI (WInGI) focus group of the Asian Pacific Association of Gastroenterology (APAGE) have been set up to study and recommend policies to facilitate greater female representation. A key measure well within the grasp of policy makers is to create more flexible training programs and workplace provisions such as part time work that enable women to train and start their careers without having to sacrifice aspirations to have children or care for a young family. Creation of an avenue to re-enter the career ladder after taking a break to start a family would reduce the attrition of female gastroenterologists from the workforce. Promotion exercises must be transparent and consider multifaceted leadership attributes. There should be no let-up in advocating for an environment that is less discriminatory and more welcoming to women embarking on a career in gastroenterology.

While there is no place for complacency, much can be achieved within a short time. It behooves us in the gastroenterology community to ensure that the abundant talent of both women and men in gastroenterology is utilized fully to the greater good.

The authors declare no conflicts of interest.