A full century after the passing of the 19th amendment, the composition of today’s medical school classes reflects the gender balance of the U.S. population. Of the country’s 92,733 medical students in 2019, 46,878 were women.1 In that year, women comprised nearly half of residents and fellows in training, and most graduate students enrolled in doctoral programs in the biological and medical sciences in the United States were women.2 The proportions of women faculty in clinical and basic science academic departments have grown steadily over the past decade, and as of 2019, nearly half of new faculty hires across all of academic medicine were women.2 In that year, some primary care and specialty fields had more female faculty and residents than male faculty and residents.2 Given these promising observations, one might ask whether the challenges associated with gender in academic medicine have been overcome. And the answer would still be no.
Evidence and Experience
Why not? Consider the data. Women continue to be underrepresented in top leadership roles in academic medicine.3 Last year, 18% of U.S. medical school deans and 19% of clinical department chairs were women, with only small increases in the past decade.4,5 That same year, fewer than 15% of academic departments of anesthesiology, emergency medicine, neurology, otolaryngology, and surgery were led by women, despite far greater proportions of senior women faculty,6 and, in 2018, one-third or fewer of senior associate deans, center directors, division chiefs, and section chiefs were women.2 Women increasingly served as assistant and associate deans in 2018—commonly working with portfolios in education, student or faculty affairs, and diversity—but were rarely appointed to oversee high-stakes and highly influential clinical or research missions.2
Recent data indicate that a smaller proportion of women attain senior rank in academic medicine compared with men, and men are more commonly promoted in 7 years in both clinical and basic sciences.3 Also, women have been less likely to successfully apply for National Institutes of Health (NIH) R01 grant renewals for many years, and a 2017 study7 found that gender stereotypes may impact the R01 renewal peer review process. In one 2015 study,8 female early-career researchers reported significantly lower institutional support than did their male counterparts (median $350,000 versus $889,000) for all strata of NIH funding. Few editors of journals in education and in scientific disciplines are women.9,10 Moreover, women are underrepresented as authors in the literature. A 2017 review11 of over 1.5 million medical research articles found that 35% of authors per author group were women. Forty percent of first authors and 27% of last authors were women.
Mentors to help women faculty deal with such challenges appear to be in short supply; a 2016 study12 published by our journal found that across 13 medical schools, 34% of female medical school faculty did not currently have a mentor and 13% had never had one at all. It is no wonder that the percentage of women who leave academic medicine has steadily increased each year, to 41% in 2019.2 The number of women joining academic medicine is not reassuring if the entrance is better characterized as a “revolving door.” Given the extraordinary intellectual talent and skill and the investment in each individual faculty recruit, loss of women faculty—at all, and especially at this rate—is of immense concern to academic medicine.
A major report13 from 2018 indicates that half of women in medical school have experienced sexual harassment, most commonly gender-based harassment, and even more women faculty, cumulatively, have these experiences across the course of their careers in medicine. And while attitudes do seem to be changing, the problem of negative gender-based experiences starts early in medical training. For instance, in the 2019 Medical School Graduation Questionnaire14 with 16,657 respondents, more than 7% of recent graduates felt that they had received lower evaluations or grades because of gender rather than performance, 6% had been denied opportunities for training or awards based on gender, and nearly 5% had been subjected to unwelcome sexual advances during the course of medical school. Sixteen percent of recent graduates had been subjected to offensive sexual remarks during their undergraduate medical education. And 1 in 5 recent graduates reported that respect for diversity had been demonstrated inconsistently in the conduct of their faculty teachers.
The experiences of recognition and respect in the academic workplace also differ by gender. Women in training and women faculty perceive higher performance expectations and “necessary behavior” to receive recognition for their merit and contribution.15–17 In specialties of medicine where men far outnumbered women, a study18 published last year found that women physicians reported more severe, frequent, and stressful microaggressions; were less likely to recommend their specialties; and were more likely to anticipate leaving medicine or retiring early due to gender bias compared with women physicians in specialties where women outnumbered men. In a recent survey2 of more than 22,000 faculty respondents, fewer women than men felt respected in the academic workplace. Moreover, in this study, 17% of female faculty, compared with 1% of male faculty, had experienced an incident of overt disrespect in the prior year. A smaller proportion of women than men (65% versus 85%) agreed that their medical school offered equal opportunities irrespective of gender. Researchers in a study published in 201419 found that work demand in an unsupportive culture more greatly undermines women’s academic success and increases work-to-family conflict more than does the same level of work demand in a culture that is seen as supportive. Such data reinforce the important role of a welcoming culture characterized by equity, inclusion, and belonging that is free of oppression, discrimination, microaggressions, and bias.20
Across society, women are expected to have greater responsibilities than men in their personal and family lives, and the field of medicine is not immune to this phenomenon, which contributes to role strain and stress. In one study21 of married or partnered young, high-achieving physician–researchers, women spent 8.5 more hours each week on responsibilities at home (“domestic” activities). Female physicians with spouses who worked full-time were more likely than their male partners to take time off upon the disruption of child care resources or services,21 a trend widely noted in the context of the present-day coronavirus pandemic.22
Greater expectations in personal and professional roles can lead to greater fatigue. Women physicians report a variety of risk factors for mental and physical illness at higher rates than men do, and often have poorer health outcomes.23–25 A 2010 meta-analysis25 found that women physicians are more emotionally exhausted than their male colleagues. For instance, a recent study24 of 253 physicians found that the risk of burnout for women was about 2 times greater than for men and that women were disproportionately likely to suffer from psychological distress, a risk factor for mental disorders. An analysis26 published in our journal in 2010 found that women in academic medicine were more likely to report never or rarely getting adequate sleep, never or rarely feeling refreshed when waking, and experiencing excessive sleepiness during waking hours.
Very worrisome are the findings of a rigorous meta-analysis of physician suicide published this year that demonstrates a significantly higher suicide risk for female physicians—higher than for other women and higher than for their male physician counterparts of the same age.27 A 2016 study28 of female physicians found that almost 50% of the women surveyed believed that they had suffered from mental illness yet did not seek treatment for reasons including limited time, fear of reporting to a licensing board, and a belief that a diagnosis would be embarrassing or shameful. My early work29–31 on medical student and resident health care, conducted with trainees from many different medical schools across the nation, showed that women were highly concerned about stigma and negative assessments (by supervisors or the dean’s office) associated with any kind of health concern. Over the years, increased health risks for women have also been observed in studies of medical students: in a systematic review32 published in this journal in 2006, first-year female medical students developed higher anxiety and depression levels than male students did. In an early cohort study33 of medical students, among those who reported excessive drinking, female students were more likely to report meeting or exceeding binge drinking levels.
Finally, across all physicians, whether in academia or in practice, tangible indications of gender inequity exist in terms of financial compensation. A recent study34 of physician pay showed a 33% pay gap favoring men in specialty fields ($372K versus $280K) and in primary care fields ($258K versus $207K). Men in this study had greater overall net worth than women in the same age brackets, and fewer women reported having paid off their education-related debt, even several years after completing their training.
The evidence, taken together, demonstrates that inequities for women in academic medicine start early and persist. Women’s experiences in training and in pursuing their careers differ considerably from those of their male counterparts.35 The stresses that accompany becoming and being a physician as a woman may result in lessened career opportunities, a pattern of departures from academic medicine, more role strain, and sometimes very negative health outcomes. Expertise well beyond my own and well beyond what is referenced in this editorial suggests that our experience in the profession of medicine reflects a larger set of concerns in society; readers are referred to an immense body of literature in gender studies,36 medical anthropology,37 and interdisciplinary social sciences38 to gain greater understanding.
won’t you celebrate with me
what i have shaped into
a kind of life? i had no model.
born in babylon
both nonwhite and woman
what did i see to be except myself?
i made it up
here on this bridge between
starshine and clay,
my one hand holding tight
my other hand; come celebrate
with me that everyday
something has tried to kill me
and has failed.
—Lucille Clifton, “won’t you celebrate with me”39
The 19th amendment stipulated that citizens could not be denied the right to vote based on sex, yet many women were still left out. Voting rights for women of color were won piece by piece in communities across the nation, until the Voting Rights Act of 1965 was passed. In academic medicine, progress at the intersection of gender and race/ethnicity has similarly been fragmented, slow, and incremental. Much remains to be done to achieve true equity. White preference, for example, has been shown in the findings of a number of studies40,41 relevant to medical school admissions and academic hiring. Women and men who identify as underrepresented in medicine (URiM) have reported racial bias in the form of microaggressions, othering, and extra workplace burdens that contribute considerably to workplace stress reported in many studies.42–44 One study45 of 25 physicians of African descent developed the term “racial fatigue” to characterize “the potential emotional and psychological sequelae of feeling isolated in a work environment in which race regularly influences behavior but is consistently ignored.”
Focusing on the intersection of gender and race/ethnicity, the failure to promote URiM women into leadership roles is of special concern. Recent data6 from the Association of American Medical Colleges (AAMC) document that 66% of clinical departments and 62% of basic science departments are led by White men. As with their male counterparts, most women in leadership roles are White: 73.9% of female chairs in clinical departments are White and 74.9% of female chairs in basic science departments are White.6 Among women who lead basic science departments, only 8% are Hispanic, 7% are Asian, and 4% are Black or African American.2 Among women who lead clinical departments, 5% are Hispanic, 11% are Asian, and 8% are Black or African American. Just 1.3% of clinical departments and 0.75% of basic science departments are led by Black or African American women. Furthermore, few full professors in U.S. medical schools are URiM women.46 Academic medicine has, as yet, failed to achieve equity for URiM women, especially for leadership roles and senior positions.2
The U.S. population, based on U.S. Census Bureau estimates in 2018,47 is 327 million, of which 13% are Black or African American and 18% are Hispanic, Latino, or of Spanish origin. With 7% of 2019–2020 matriculants identifying as Black or African American and 6% of 2019–2020 matriculants identifying as Hispanic, Latino, or of Spanish origin, the body of medical students in the United States does not reflect the U.S. population.48 The nonrepresentative distribution of women physicians by race/ethnicity within medicine is well characterized in the American Medical Association Physician Masterfile database.49 It is astonishing to note that there are 60 or fewer Black or African American women physicians who specialize in neurosurgery, orthopedic surgery, pulmonary medicine, or urology in this country of 3.8 million square miles, and there are 60 or fewer Hispanic women physicians who specialize in neurosurgery, orthopedic surgery, pain management, or pulmonary medicine. In light of the evidence that a more diverse workforce leads to better health care for underserved communities,50 the underrepresentation of people from different backgrounds in medicine may continue to perpetuate health disparities. Given health disparities for minority populations and heightened mortality among urban Black or African American and Hispanic, Latino, and Spanish-origin communities, the lack of sufficient representation is deeply troubling and should be a call to action.
According to a cohort study51 of 27,504 graduating medical students in 2016 and 2017, women who identified as a sexual minority reported higher rates of mistreatment than did their male and heterosexual colleagues. In this study, female medical students who identified as Asian, as belonging to a URiM group, or as having a multiracial background also reported higher rates of mistreatment than did male and White students. A study published in 200352 found that lesbian physicians were more likely to report histories of depression, sexual abuse, and orientation-related workplace harassment than were heterosexual female physicians. In a 2011 study,53 physicians who identified as lesbian, gay, bisexual, or transgender (LGBT) reported high rates of social ostracism (22%), derogatory comments at work about individuals identifying as a sexual minority (65%), and discriminatory treatment of sexual minority coworkers (27%). In a 2018 study,54 18% of respondents reported using negative coping strategies to respond to stress related to their LGBT or other sexual or gender minority (LGBTQIA+) identity.
Little is known about the barriers and inequities experienced by transgender women of all races and ethnicities in academic medicine. According to recent data reported by the National Academies of Sciences, Engineering, and Medicine,55 in the general population, transgender women suffer some of the greatest health disparities. In 2016, over 1.4 million Americans (0.6%) identified as being transgender,56 and, on the 2019 AAMC Medical School Graduation Questionnaire,14 of the 15,541 respondents who answered questions about gender identity, 0.4% identified as having a gender identity different from their sex assigned at birth.
Other important and underappreciated issues exist at the intersection of gender and minority identity related to religious beliefs. A 1999 study57 reported that female physicians are more likely to practice religions that are underrepresented in the United States and thus are at risk for compounded discrimination. Women physicians, compared with other Americans, were 6 times as likely to be Jewish, 4 times as likely to be Buddhist, 9 times as likely to be Hindu, and 9 times as likely to be atheist or agnostic.57 In one study58 of Muslim physicians, 24% of respondents stated that they encountered religious discrimination during their careers and 14% of respondents reported that they currently experienced religious discrimination at work. The risk of discrimination was higher for those who reported that their faith was of deepest importance in their lives.
Disability status may further contribute to inequity and distress for female physicians who already experience gender bias. While 12.6% of the U.S. population reported living with a disability in the U.S. Census’s 2017 American Community Survey,47 just 2.3% of 15,653 medical students reported a disability in the 2019 AAMC Medical School Graduation Questionnaire.14 Within this small percentage, a significant number of participants reported a mental health issue, a learning disability, or a mobility or sensory impairment. Some respondents reported being denied accommodations associated with their reported disability. Evidence suggests that health professionals perceive disabilities negatively, perhaps even more so than the members of the general population do.59
Intersectional analyses of race and gender make it clear that experiences of discrimination are compounded by additional overlapping marginalized identities. The tasks at hand are to question accepted practices and norms and to recognize and address structural forces that promote racism on a systemic level. On a more individual level, we must ensure that marginalized members of academic communities are fully respected, protected from discrimination, offered opportunities, and supported along their professional journeys.
In This Issue of the Journal
In this issue of Academic Medicine, we have assembled a collection of reports and essays on the experiences of women in medicine that offer thoughtful approaches to reversing the tide of gender and identity-based inequities.15,16,60–72 Analyses presented by our authors document gender-related disparities and differential challenges for women in academic medicine (e.g., in interactions with colleagues60; in faculty retention, attainment, and productivity61; and in compensation62).
Pelley and Carnes62 ask the field to evaluate the negative impact of gender segregation and gender bias in the specialties of medicine and the consequences for health-related research and policy. They state persuasively that disparities will not change without “cultural transformation of existing gender norms which are ubiquitous, continually reinforced, and have shown relatively little change over decades.” Barnes et al72 identified the 4 themes of exclusion, increased effort, adaptation, and resilience to workplace slights in the experiences of 23 female surgeons at different professional development stages. Trainees reported the highest rates and severity of microaggressions and bias experiences. The specific gender-related challenges in the culture of surgical disciplines were also noted in the Invited Commentary by Greenup and Pitt.71
Research reports by Todd et al63 and by Stack et al64 provide insights into the experiences of residents related to childbearing and parenting; these reports highlight some of the personal and family health issues experienced by women residents and elevate concerns regarding parental leave policies, pregnancy complications and negative outcomes, and the intensity of physical and psychological stresses encountered in clinical training. Reduced fertility and adverse experiences in pregnancy are very troubling and warrant attention. Further, heteronormative expectations of women in medicine—for example, to be married to members of the opposite sex, to have children, or to be capable of healthy pregnancies—can contribute to the feeling of being different, excluded, and/or of not belonging.
Immediate action to promote gender equity is the focus of the agenda laid out by Acosta et al.65 Rejecting the status quo, they outline a rigorous equity initiative that systematically entails investment of resources and new approaches to recruitment, promotion, and hiring policies, with clearly defined metrics, leadership imperatives, and requirements for authentic inclusivity. Jagsi and Spector66 provide a compelling description of the Executive Leadership in Academic Medicine program and its impact over the past 25 years in supporting over 1,000 women leaders in academic medicine, 29% of whom identified as members of racial or ethnic minorities. Valantine67 describes efforts over several years at the NIH to promote the research and academic success of women across medicine and the biomedical sciences. Such efforts are intended to create environments that support women in academic medicine, as previously demonstrated by Westring et al,73 who found that freedom from gender bias, support for work–life balance, equal access to opportunities, and a supportive chair or chief created a culture that was conducive to women’s academic success. Such efforts strengthen academic medicine and demonstrate a commitment to a more just future for our profession.
Bias, discrimination, and an exclusionary culture persist in academic medicine,3,40–42,74 despite our ideals and intentions. These adverse forces result in inequity, distress, and negative professional and personal consequences among historically underrepresented groups in medicine, including women.13 Even greater challenges are encountered by women with a nonmajority racial, ethnic, cultural, or religious identity and by LGBTQIA+ individuals.75 The health status and disability status of women in academic medicine may also be sources of compounded inequity, distress, stigma, and negative career outcomes.28,76 Such disproportionate, enduring burdens based on gender or identity are unjust and are antithetical to the values and social contract of academic medicine.77
Let us remember, Dear Reader, that many women were publicly humiliated, beaten, imprisoned, and killed on the path to suffrage in the United States.78 The deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery, among others, provide irrefutable proof of grave injustice in our world as well as the inherent precariousness and preciousness of societal trust. Movements such as White Coats for Black Lives,79,80 Time’s Up,81 and Black Lives Matter82 are vitally important both in their messages and their impacts.83 Our aspirations to build a respectful, inclusive culture20 in which the dignity of each member of our community is honored must be accompanied by actions to combat discrimination, harassment, and bias and to acknowledge and repair the consequences of these injustices.
The imperative to address inequity for women in academic medicine is clear. Proactive efforts to support opportunity, academic success, and well-being for women and to address discrimination, harassment, and bias are overdue. Our efforts will not be correct or sufficient, though, unless we also bring forward equity for individuals of all historically underrepresented groups. “Tied in a single garment of destiny,”84 we in academic medicine must work together to attain social justice, fulfilling the obligations and aspirations of academic medicine.
Laura Weiss Roberts, MD, MA
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