key: cord-0774968-9lc09itw
authors: Søgaard, Mette; Nilsson, Kristine Lilholt; Tacconelli, Evelina
title: The SARS-CoV-2 pandemic puts the spotlight on gender inequality in clinical research
date: 2021-04-01
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2021.03.022
sha: 17dd89d01d4d53fae2a4877516f6fa83351d442c
doc_id: 774968
cord_uid: 9lc09itw

nan

At the time of this writing, the coronavirus disease 2019 (COVID-19) pandemic has claimed over 2,5 million lives worldwide and disrupted all aspects of human society. Stay-at-home orders, lockdowns and school closures have also affected academia. Emerging evidence suggests that the constraining effects of the pandemic disproportionately affect female academics. Across all disciplines, women's productivity and scientific output has fallen relative to men's [1] . Compared with nearly 40,000 papers in US medical journals in 2019, women's shares of overall, first, and last authorship in COVID-19 papers, decreased by 16%, 23%, and 16%, respectively [2] , and the pandemic has put a spotlight on highlighted constraints faced by women in academia [3] . This manifests not only in fewer publications, but also in terms of public exposure; women make up just 24% of COVID-19 experts quoted in the media and 24.3% of national task forces [4] .

In this issue of Clinical Microbiology and Infection, Cevik et al [5] reviewed leadership committees and authorship of COVID-19 clinical trials between January 1, 2020 and June 26, 2020. Less than one third of the trials were led by women; 27.3% had a female principal investigator, 28.7% had a female study director, and only 31.4% had a female study chair. Exclusion of women from clinical trial leadership not only impact publication productivity but also career benefits including international recognition and networking, access to funding, and institutional and media acknowledgment. The resulting loss is tangible and particularly worrisome if, as we expect, the impact will go beyond the pandemic.

Gender inequality in academia is not new None of these constraints are new. Even before COVID-19, women were underrepresented in the top tiers of academic medicine; they are promoted at a lower rate and are less likely to serve in leadership positions and boards than male colleagues [6, 7] . Women lack equal representation in J o u r n a l P r e -p r o o f speaking engagements at conferences, experience disparities in the awarding of grants, and earn less than male colleagues even after adjustment for differences in faculty rank, age, experience, and measures of productivity [6, 7] . Women belonging to the underrepresented minority (e.g., race or ethnicity, sexual orientation, and socioeconomic status) are particularly underrepresented. On top of this, the SARS-CoV-2 pandemic has led to unprecedented social measures as day care, school and workplace closures, which have disproportionally exacerbated the work challenges for women.

Women's underrepresentation in academia is historically viewed as a phenomenon related to women choices (the eternal work-family conflict) rather than the organization. It is often speculated that women's preference for non-science disciplines and their tendency to take on a disproportionate amount of child-and family-care are the primary causes of gender disparities in academia, leading some to conclude that gender discrimination does not exist nor contribute to the inequalities within academia [8] . Indeed, the "imposter syndrome", which refers to chronic feelings of inadequacy and fear of being discovered as an intellectual fraud despite proofs of talent and achievements, is known to affect women more than men [9] . Other factors advanced as explanations include career choice, years of experience, number of hours worked, and lack of mentors and senior role models [6, 7] . The lack of women in leadership positions have also been referred to as a pipeline problem, but women have made up about half of medical graduate students in European countries and the US since 1994 [10] .

It could be argued that the slow progress simply reflects the sheer length of the path to senior positions and the lag time before the predominance of male professors and chairs retire. If so, representation of women would initially increase in early ranks and then later in senior positions.

Nonetheless, despite equal representation of female medical graduates for decades, this has not J o u r n a l P r e -p r o o f materialized [11] , giving rise to the metaphor of a leaking pipeline. Professors and chairs tend to select coworkers, board members or project leaders according to criteria, which have been developed and validated on the stereotype of the male leader. The phenomenon known as "the old boys' club" refers to the advantage that males have over their female colleagues in interacting with powerful male leaders. For example, when male employees are assigned to male managers, they are promoted faster than their female counterparts [12] . Lack of women at higher ranks and social norms related to traditional gender role expectations may reinforce and perpetuate this cycle.

Moreover, studies have shown that women at the top of organizations may be more interested in conserving their position instead of educating and supporting colleagues at the bottom to learn how they can best assimilate into the prevailing norms. Gender disparities are also evident in daily activities in academia. Female researchers are less likely to be properly introduced by their title at grand rounds than male researchers [13] . Research also shows that women fare better in gender blind evaluations of their CV. In a randomized, double-blind study, science faculty at researchintensive universities were provided fictional application materials from equally qualified men and women [14] . Both male and female faculty in the study rated the male applicant as significantly more competent and hirable than the (identical) female applicant and offered higher starting salary and more career mentoring to the male applicant [14] .The fact that the bias is reproduced by faculty members of both genders is an indication of the magnitude of the challenge. Subtle and unintentional acts like these contribute to marginalize female researchers and can negatively affect career trajectory and satisfaction.

Gender equality is not just a question of securing equal benefits or career advancement. It is crucial for producing the best research by leveraging talent and increasing innovation and group J o u r n a l P r e -p r o o f performance, thereby supporting provision of the best care for patients [15] . Research has demonstrated that diverse teams in terms of gender, ethnicity, and social background have a higher collective intelligence, produce better health science, are more highly cited, generate a broader range of ideas and innovations, and better represent society [16] . Thus, drawing on all gender talents is essential to spur productivity and quality. A gender equitable workforce is key to enhancing the quality of science by ensuring continued excellence and maximizing the talent in academia. When failing to overlook the entire talent pool important perspectives are missed, and inequalities may be perpetuated or worsened, thereby creating a vicious circle preserving a patriarchal culture.

Many have called for gender parity (e.g., numeric equality in representation by sex). However, improvements in numbers alone does not necessarily equate to gender equality; in an era in which women have closed the gap with respect to medical school admission, gender equity has not yet been achieved as highlighted in this commentary. To fix the leaking pipeline, cultural change is necessary-and culture can only change if we all share the responsibility. As UN secretary-general António Guterres put it in a speech about women and power in February 2020: "It is time to stop trying to change women, and start changing the systems that prevent them from achieving their potential" [17] . As women, we need to speak up and share our story to advance change. Academic and non-academic institutions should proactively and deliberately create policies and interventions to overcome the unconscious biases underlying gender inequalities, in order to shape cultural and social attitudes, and to support recruitment, retention, and advancement of women in academia.

Many universities have already launched such initiatives, but progress has been slow and insufficient to bring about the widespread social changes needed. Funders also have a responsibility to consider the constraints faced by women scientists in grant applications. From 2021, the European Commission will require all public bodies applying to Horizon Europe -the new European flagship, €81-billion (US$96-billion) research and innovation funding programme -to have gender equality action plans [18] . Many scientific journals have made public commitments to promote gender equality and diversity with respect to authorship and editorial boards. Similarly, organizing committees of academic meetings and scientific conferences should make a concerted effort to ensure gender balance in panels and keynote speaker selection. Already, many high-profile researchers are taking a stance against all-male speaking panels. Francis Collins, MD, PhD, director of the National Institutes of Health, recently announced "I want to send a clear message of concern:

It is time to end the tradition in science of all-male speaking panels …. Starting now, when I consider speaking invitations, I will expect a level playing field, where scientists of all backgrounds are evaluated fairly for speaking opportunities [19] ."

The path ahead Vaccine approvals and launch of mass vaccination programs worldwide offers hope that the end of the SARS-CoV-2 pandemic will soon be in sight. For gender equality there is no "vaccination fix".

Gender inequality is an injustice potentially leading to loss of gender talent across all scientific fields. The solution calls for new weapons. Gender education, implementation of national regulations to promote equal access to career and research opportunities, and audits to assess that each university and research center is moving in the right direction are some of the possible actions.

While progress has been made, the accumulating evidence underlines that work remains to be done to allow women to be fully equal to men. The pandemic has shown how easily the progress and milestones achieved in the gender equality field can be cancelled. We are realizing that the burden J o u r n a l P r e -p r o o f 8 of the SARS-CoV-2 pandemic will likely go beyond the dramatic number of deaths with currently severely underestimated effects on society and social structures a whole. 

Are women publishing less during the pandemic? Here's what the data say

COVID-19 medical papers have fewer women first authors than expected

Equalities in freefall? Ontological insecurity and the long-term impact of COVID-19 in the academy. Gender

Governance of the Covid-19 response: a call for more inclusive and transparent decision-making

Gender disparities in COVID-19 clinical trial leadership

Gender equity in epidemiology: a policy brief

Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians

Science gender gap probed

Imposter syndrome threatens diversity

Sex Differences in Academic Rank in US Medical Schools in 2014

Women Physicians and Promotion in Academic Medicine

The Old Boys' Club: Schmoozing and the Gender Gap

Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias

Science faculty's subtle gender biases favor male students

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Make this the century of women's equality: UN chief

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