The gender gap in French articles in anaesthesiology

Editor, The gender gap is a major concern in many fields of professional activity, including sciences and medicine.1,2 In France, girls makes up the majority of students at university, and women have a higher success rate than men at undergraduate level. Women have a higher success rate than men at undergraduate level.3 In contrast, only 15 to 20% of university professors of medicine (highest level) are women.3 Similar proportions are observed for chiefs of staff or heads of departments in France. Even though there are disparities between scientific fields, or even between medical or surgical specialities, there are also wide international disparities. For example, in Iceland and Portugal, more than 60% of PhDs are women whereas the average in the Organisation for Economic Co-operation and Development (OECD) countries is 46% (43% in France).3 In the specific field of anaesthesiology, the proportion of women anaesthesiologists remains low: 35% in 2010 and rising to 37% in 2018.4 Several studies have shown that gender inequalities are present in medical scientific publications; however, no study has ever investigated gender inequalities in publications in anaesthesiology in France. We studied articles published in Anesthesia, Critical Care and Pain Medicine (ACCPM), the official journal of the French Society of Anesthesia and Intensive Care that has a quarter of the specialty's physicians as active members. Summaries of each issue were reviewed from February 2015 (first issue) to June 2019. Original articles were selected. For each of these articles, we recorded the year of publication, the number of authors and the declared gender and the rank of each author. We excluded articles when first or last authors belonged to a non-French team. When the first name was not provided or indeterminate, the author's gender was searched among the available affiliation information or through direct contact (authors or institution). Our primary endpoint was the proportion of female authors as the first or last author. Our secondary endpoints were the overall proportion of female authors, their frequency as second or third author and their frequency in significant rank (first, second, third and last author). To study the evolution of our primary end-point over time, we analysed the three chronological terciles of published articles. Comparisons were performed using χ2-tests. Finally, in order to exclude selection bias, we counted female authors as total, first or last authors in French teams’ publications in convenience samples including the last 30 consecutive articles in two other main journals of anaesthesiology, the European Journal of Anaesthesiology (December 2018 to February 2020) and Anesthesiology (January 2019 to February 2020). Twenty-six volumes of ACCPM were studied, including 273 articles. Thirty-one (11%) articles were excluded as the first or last author belonged to a non-French team. Finally, 242 (89%) articles including 1890 authors were analysed and 461 (24%) of these authors were women. The incidence of women as first or last author was 21% (28% as first author and 13% as last author, P = 0.01). Results are shown in Table 1. The incidence of females as first or last authors was 23% during the first tercile (February 2015 to August 2016), 22% during the second tercile (October 2016 to February 2018) and 20% during the third tercile (April 2018 to August 2019) (P = 0.9). The proportions of female authors in the European Journal of Anaesthesiology and Anesthesiology were, respectively, 25% (56/227) and 28% (45/162), not different from ACCPM (P = 0.7). The number of females as first or last authors in the European Journal of Anaesthesiology and Anesthesiology were, respectively, 13% (4/30) and 30% (9/30) (first author) and 1% (3/30) and 15% (4/26) (last author), not different from ACCPM (P = 0.2 and 0.3) (Table 2). Table 1 - Gender and author's ranking distribution in published articles by French anaesthesiologists in Anesthesia, Critical Care and Pain Medicine (ACCPM) from February 2015 to June 2019 Total authors First author Last author Second author Third author Other position Female 461/1890 (24%) 68/242 (28%) 32/242 (13%) 82/242 (34%) 77/242 (32%) 202/922 (22%) Male 1429/1890 (76%) 174/242 (72%) 210/242 (87%) 160/242 (62%) 165/242 (68%) 720/922 (78%) Total 1890a (100%) 242b (100%) 242b (100%) 242b (100%) 242b (100%) 922c (100%) P – 0.2 0.0001 0.0002 0.004 0.01 Values are ratio (%).aTotal of all authors regardless of their gender in all published articles.bTotal of all articles with at least four authors.cTotal of all authors regardless of their gender other than first, second, third or last author. Table 2 - Gender and author's ranking distribution of French anesthesiologists in the 30 last and consecutive articles published by Anesthesiology (from January 2019 to February 2020) and European Journal of Anaesthesiology (from December 2018 to February 2020) Total of female authors Female as first author Female as last author Anesthesiology 45/162 (28) 9/30 (30) 4/26a (15) European Journal of Anaesthesiology 56/227 (25) 4/30 (13) 3/30 (10) P ∗ 0.7 0.2 0.3 Values are ratio (%).∗P-value calculated when comparing results of each journal to ACCPM results.aOut of 26 articles with at least four authors. The frequency of female authors was low in ACCPM, amounting to 24% of all authors. Moreover, it was lower regarding the significant ranks, such as first or last authors (21%). Women are clearly under-represented in authorship in French anaesthesiology articles. Furthermore, our results cannot be explained by a hypothetical voluntary choice of French female authors to publish consistently in journals other than the French ACCPM Journal. Of note, because last authors are usually full professors and first authors are more often juniors, we hope that in 15 years from now there will be more women as full professors signing as last authors on scientific publications. The rate of publications with a woman as first or last author was close to 25% in Science and reached one-third in The Lancet Infectious Diseases.2,5 In contrast, in psychiatry, women as first authors reached 44% in 2018.6 Actions have to be taken to close the gender gap at least in scientific production in the field of French anaesthesiology. Nevertheless, our results have to take into consideration the proportion of women within each specialty. The proportion of women anaesthesiologists in France was 37% in 2018. Therefore, this can explain the quite low global rate for women in publications but does not explain why they were under-represented in significant ranks. Thus, efforts should be made to better understand the early determinants of women's participation in research in medicine, and especially in anaesthesiology. As for other fields with fewer female students, some of those determinants could be linked to social and environmental factors, such as negative stereotypes, gender bias or residual inequities in family responsibilities.7 However, beyond those social prevalent factors, the climate of academic research and persisting conservative institutions can also widen the gender gap. Rosso et al.7 investigated the personal experience of academic physicians: women were under-represented in academic positions among intensivists and anaesthesiologists and they reported prejudices during the academic selection and promotion processes. However, there were no gender differences in scientific production. Thus, it is likely that the impediment to female student investment in scientific research has settled upstream during medical studies. The authors suggest implementing changes in the undergraduate curriculum. Setting up leadership workshops and mentorship could also be an interesting solution to empower female students, helping them to gain self-confidence so as to embrace academic careers. Similar investigations should be undertaken in other countries and specialities. The gender gap still exists in medical research; even if several cracks have appeared in the glass ceiling, there is still much to be done so as not to lose further talent.