Women are traditionally underrepresented in academic medicine, including, but not limited to, as authors in anesthesiology journals1; however, considerable variation occurs across subspecialties. Within neuroanesthesiology and neurocritical care, gender representation of authors has remained undefined. In this issue of the Journal of Neurosurgical Anesthesiology, Gupta et al2 present an analysis of gender representation among first and corresponding authors in neuroanesthesia and neurocritical care journals—the Journal of Neurosurgical Anesthesiology, the Journal of Neuroanaesthesiology and Critical Care, and Neurocritical Care—between 2015 and 2020. We congratulate Dr Gupta and colleagues’ efforts in addressing this knowledge gap within our subspecialty.
Within the 1164 neuroanesthesia and neurocritical care publications included in their analysis, Gupta et al2 identified that women held 35% and 30% of first and of corresponding author positions, respectively. In addition, women first authors were most commonly affiliated with an institution in the United States (39%) or India (31%), whereas women corresponding authors were most frequently identified as being affiliated with an institution in India (39%). Women had the lowest representation as authors of original research articles in comparison to special articles, review articles, and clinical reports.
The results of this analysis are consistent with previous reports in the neurosciences. A prior analysis of the greater neuroscience literature between 2005 and 2017 found that 30% of authors were women, with a higher proportion of women as first authors (33%) compared to senior authors (18%).3 Interestingly, another study found that the number of women authors was inversely proportional to a journal’s impact factor.4 The lowest representation of female first and last authors were both in Nature (25% and 15%, respectively), whereas the highest representation of female first and last authors were in Neuropsychology Review (53% and 39%, respectively).3
Authorship and article citation are 2 metrics required for academic promotion and success, yet gender bias and homophily—a process by which like associates with like—represent barriers that impede women from advancing in their academic careers. In 2003, women made up 50% of neuroscience PhD students, 25% of tenure-track faculty, and 22% of tenure-track full professors in the United States.5 The following 15 years brought about no improvements as women made up 53% of PhD matriculants but only 31% of tenure-track faculty and 14% of tenured full professors in 2017-2018 in top-ranked US neurology programs.6 Not only do publications have downstream effects for recognition, collaboration, and career advancement, citational practices can also have material effects. A study examining the publications within the top 5 neuroscience journals demonstrated that articles with men in first and senior authorship positions were cited more often and that this preferential citational practice increased over time.7 The precise reasons behind the underrepresentation of women in academic medicine, senior academic positions, and research are multifactorial and likely extend beyond traditional metrics of productivity.
Research such as the study by Gupta et al2 is necessary to define gaps in equity, and such research must carefully recognize the distinction between sex and gender. Delineating these concepts has been vital in long-standing feminist efforts to disrupt the notion that sex dictates gender. In de Beauvoir’s8 The Second Sex, “One is not born, but rather becomes, a woman” distinguishes sex from gender. Sex consists of biological differences, something that we are, whereas gender is a socially constructed phenomenon, something that we do that is grounded in culture, history, and politics.9 Butler expands on gender and introduces a concept known as gender performativity; that is, we do not choose which gender we will be one day but rather that we reiterate subjectivating norms by which we are constituted, constraining a gendered subject.9 Butler goes on to dismantle the notion of an ontologically fixed gender identity, one that traditionally in medicine revolves around the gender binary. Conflation of sex and gender in research is common, and differentiating sex and gender constructs are crucial in clinical care, policy creation and implementation, and in research. The terminology used must align with the construct of choice; that is, if gender is the construct of interest, then gender-related terminology should be used. Moreover, the use of inappropriate terminology may be perpetuated by citing publications using the same sex-related or gender-related terminology utilized within the parent article.
The underrepresentation of women in clinical and academic neuroscience highlights the need to identify interventions employing antioppressive frameworks to ensure an equitable and diverse workforce. Meritocracy does not account for historically driven structural imbalances, and further research should identify active, nonperformative measures to ensure the inclusion of all people from socially marginalized groups. Future research must also extend beyond the gender binary (ie, women/men, feminine/masculine) and incorporate the voices of transgender, gender nonbinary, gender nonconforming, and 2-spirited people who are often silenced and homogenized. Research of this nature ideally should move to prospective designs where participants can self-identify, rather than assigning a “gender” based on names or phenotypic traits; assigning social constructs strips people of their agency, is a dehumanizing practice, and is, therefore, a form of structural violence. Finally, oppressive practices do not strictly occur neatly along a sole axis of oppression, and future research should introduce intersectionality to better understand intersecting axes of subordination across a spectrum of social constructs—including, for example, race, ethnicity, religion, caste, etc.—and the power dynamics at play.
In the area of gender equity, progress is underway to address gaps in participation in research, as seen in the study by Gupta et al.2 For example, the Society for Neuroscience in Anesthesiology and Critical Care introduced the Women in Neuroanesthesiology and Neuroscience Education and Research (WINNER) program to highlight and celebrate women’s accomplishments in the specialty as well as to support and mentor young and mid-career women. General strategies such as increasing awareness of bias and stereotypes, mentorship/sponsorship, and addressing the pay gap have also been recommended.10
The study by Gupta et al2 is a great initial step towards defining the current state of gender equity in neuroanesthesia and neurocritical care and reports metrics that can act as a baseline upon which to measure future change. As outlined above, Gupta et al2 also highlight additional gaps in our knowledge and the need for evidence-based interventions to increase opportunities for women and all socially marginalized people in academic medicine.
Gianni R. Lorello, BSc, MD, MSc (Med Ed), CIP, FRCPC*†‡§
Alana M. Flexman, MD, FRCPC∥¶
*Department of Anesthesiology and Pain Medicine, University of Toronto
†Department of Anesthesia and Pain Management, Toronto Western Hospital—University Health Network
‡The Wilson Centre, University Health Network
§Women’s College Research Institute, Women’s College Hospital, Toronto, ON
∥Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia
¶Department of Anesthesia, St. Paul’s Hospital, Vancouver, BC, Canada
G.R.L. thanks the Department of Anesthesia and Pain Management at the University Health Network—Sinai Health Systems for his continued academic support.
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8. de Beauvoir S. The Second Sex. London, UK: Vintage Books; 2011.
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