Introduction
In the medical field, authorship is notably linked to career advancement, making gender
equity in scientific authorship and equal opportunities in research a topic of great
interest. When analyzing the medical profession, it is worth noting that over half
of medical students are female; however, in the USA, the majority of admitted residents
are men and, during their careers, they are more likely to obtain leadership positions
endowed with decision-making and budget power [1 ]. In fact, according to a recent review, in 2018, women represented 29% of division
and section chiefs, and 18% of department chairs [2 ]. Furthermore, a recent study published in the Journal of the American Medical Association demonstrated that women receive fewer awards and, as a result, have access to less
funding [3 ].
With regard to academic medicine, women have been found to be less likely to secure
senior faculty positions and to experience slower promotion [4 ]
[5 ]. As a result, gender-based disparities have been observed in the authorship of academic
literature and medical education journals [6 ]. Furthermore, women remain under-represented on editorial boards of influential
medical journals [7 ], and women with comparable experience and qualifications are less likely than men
to be invited to publish editorials [8 ]. The specific field of gastroenterology and endoscopy is no exception.
An important descriptive study published in Gastrointestinal Endoscopy in 2015 assessed the situation by evaluating the percentage of female authors in
the five most influential American gastroenterological journals during a span of 20
years (1992–2012) and demonstrated a slow increase in female authorship, with the
proportion of first female authors (FFAs) rising from 9.1% to 29.3% and of senior
female authors (SFAs) increasing from 4.8% to 14.5% [9 ].
Unfortunately, the absolute number of female and male gastroenterologists worldwide
and their distribution among the specific subspecialities (e.g. endoscopy, gastroenterology,
inflammatory bowel disease [IBD], hepatology, etc.) is not known. We believe however
that analyzing authorship in scientific publications is important because it provides
valuable insights into whether gender imbalance exists in the scientific community
or not. There is a lack of recent studies, especially involving European countries
and journals, that have tracked the latest developments in this area or offered more
specific explanations for this phenomenon.
This observational retrospective study aimed to give a snapshot of the role and representation
of women gastroenterologists in the field of science.
Methods
The authorship was evaluated in articles already published and in ongoing research
over the last 3 years (2020–2022). The analysis focused on articles from ten high
impact factor (IF) journals that specialize in gastroenterology and hepatology, five
based in the USA and five based in Europe. US-based journals were labeled “Group 1”
and were as per those in the previous article published by Long et al. [9 ]. The European-based group were labeled “Group 2.” Both groups provided substantial
representation of the subcategories in the field of gastroenterology (general gastroenterology,
hepatology, endoscopy, and IBD).
Journals included in Group 1 were Gastroenterology (IF 33.88), Hepatology (IF 17.42), American Journal of Gastroenterology (AJG; IF 10.86), Clinical Journal of Gastroenterology and Hepatology (CGH; IF 11.38), and Gastrointestinal Endoscopy (GIE; IF 9.42). Group 2 included Journal of Crohn’s and Colitis (JCC; IF 10.02), Digestive and Liver Disease (DLD; IF 5.16), Journal of Hepatology (IF 30.08), Gut (IF 31.79), and Endoscopy (IF 10.43). The articles included were editorials and original articles from authors
from all countries; case reports, case series, meta-analyses, guidelines, and reviews
were excluded.
Data extracted for each article included the first, second, and senior (last listed)
authors’ gender and institutional nationality, the type of article (editorial/original
article), study design (retrospective/prospective), type of research (clinical/preclinical),
and topic (endoscopy, hepatology, upper and lower GI, IBD, and other). The parameter
“study design” was applied only for original research. The author’s gender was first
determined on the basis of the name, with further verification made by visiting the
institutional website and performing Google search engine research.
For the ongoing research, the data were collected from clinicaltrials.gov, searching
“gastrointestinal” and applying as filters “recruiting” and eligibility criteria “adult”
and “old adult.” Data extracted for each ongoing research project were the gender
of the principal investigator (PI) and the country of their institution, the topic
(diagnostic/therapeutic endoscopy, upper GI/lower GI, IBD/hepatology/biliopancreatic
tract/cancer/other), study design (retrospective/prospective), and type of research
(clinical/preclinical).
Statistical analysis
Statistical analyses were performed using STATA software. Categorical variables are
expressed as absolute numbers and percentages.
The frequency of authorship stratified by the author’s gender was calculated for Group
1 and Group 2. A chi-squared test was used to compare Groups 1 and 2 to evaluate a
possible difference in publications among men and women based on the country of the
journal (US- vs. European-based journals). The chi-squared test was also used to study
the association of the first and senior authors’ gender.
Univariable logistic regression analysis was performed to identify factors associated
with female authorship as the primary outcome, defined as having an FFA and/or SFA,
and results are presented in terms of odds ratios (ORs) with 95%CI. The factors analyzed
were the journal, type of article (editorial as the reference), study design (retrospective
study as reference), type of research (preclinical as reference), and topic of the
research (endoscopy as reference). The same analysis was performed for ongoing research.
Results
The articles identified were US-based (Group 1) in 52.4% (n=2205) and European-based
(Group 2) in 47.6% (n=2002).
Authorship per journal and type of article
Among published articles in Group 1, 496/2205 (22.5%) were editorials; in Group 2,
editorials made up 295/2002 (14.7%).
The overall proportion of FFAs was 1408/4207 (33.5%) and of SFAs was 911/4207 (21.7%).
In Group 1, we found 693/2205 (31.4%) FFAs and 457/2205 (20.7%) SFAs; in Group 2,
we found 715/2002 (35.7%) and 454/2002 (22.7%), respectively. In the comparison between
Groups 1 and 2, US-based journals showed a statistically significant lower percentage
for FFAs (P =0.003), but not for SFAs (P =0.12).
In the analysis for single journals, the lowest percentage of FFAs was in GIE (23.05%;
OR 0.55 [95%CI 0.45–0.67]; P <0.001), followed by Endoscopy (24.55%; OR 0.63 [95%CI 0.48–0.84]; P =0.001) and Gastroenterology , but this last one was not statistically significant (31.0%; OR 0.92 [95%CI 0.76–1.11];
P =0.40). The percentage of SFAs was 9.1% in CGH (OR 1.21 [95%CI 0.39–3.77]; P =0.73), followed by 12.3% in Endoscopy (OR 0.48 [95%CI 0.33–0.70]; P <0.001) and 14.8% in GIE (OR 0.58 [95%CI 0.46–0.74]; P <0.001).
Univariable logistic regression found a statistical association between female authorship
and the type of article (editorial or original article), with the percentage of editorials
published by men being higher than by women (original article, OR 1.92 [95%CI 1.58–2.33];
P <0.001). Women were the first author in 35.8% of original articles and 23.4% of editorials.
Finally, a female physician had a higher likelihood of being the first author if the
senior author was a woman rather than a man (P <0.001), both for the US-based and European-based journals. An FFA was found in 468/911
(51.4%) of articles with an SFA and in 934/3296 (28.3%) in articles with a male senior
author.
Authorship and topic of the research
Out of 4207 articles, 1112 (26.4%) dealt with endoscopy, 1573 (37.4%) were focused
on hepatology, 588 (14.0%) on IBD, 668 (15.9%) dealt with upper and lower GI disease,
and finally 266 articles (6.3%) were focused on other topics not included in the previous
categories. For this analysis, we considered “articles published by a female gastroenterologist”
to be all articles in which there was an FFA, SFA, or both. Of the articles about
endoscopy 348/1112 (31.3%) were published by a female gastroenterologist. For the
non-endoscopic topics, the percentages were 792/1573 (50.3%) for hepatology, 281/588
(47.8%) for IBDs, 304/668 (45.5%) for upper and lower GI disease, and 127/266 (47.7%)
for other topics, respectively.
In the comparison of endoscopic vs. non-endoscopic topics, logistic regression (endoscopic
topic as reference) found an association between female authorship and publications
about hepatology (OR 2.15 [95%CI 1.83–2.55]; P <0.001), IBD (OR 2.12 [95%CI 1.60–2.45]; P <0.001), upper and lower GI (OR 1.31 [95%CI 1.18–1.73]; P =0.003), and others (OR 1.61 [95%CI 1.15–2.44]; P =0.002) ([Table 1 ]).
Table 1 Female authorship stratified by the topic of the research.
Odds ratio
95%CI
P value
GI, gastrointestinal.
Endoscopy
1
1
Hepatology
2.15
1.83–2.55
<0.001
Inflammatory bowel disease
2.12
1.60–2.45
<0.001
Upper and lower GI disease
1.31
1.18–1.73
0.003
Others
1.61
1.15–2.44
0.003
In the analysis of the authorship position of the female author, the highest rate
of FFAs was seen in hepatology (594/1573; 37.8%) and IBD (220/588; 37.4%); the highest
rate of SFAs was seen in hepatology (391/1573; 24.9%) and upper and lower GI (141/668;
21.1%). The lowest rate of FFAs was seen in endoscopy (262/1112; 23.6%); the same
topic also showed the lowest rate for SFAs (170/1112; 15.3%).
Authorship and design of the research
In the analysis of research design, the parameter “prospective vs. retrospective”
was evaluated only for original articles and was collected for 3088/3416 articles
(90.4%). The type of research defined as “preclinical vs. clinical” research was applied
for all of the published articles and information was collected for 4107/4207 published
articles (97.6%). For this analysis, we considered “articles published by a female
gastroenterologist” to be all articles in which there was an FFA, SFA, or both.
A significant association with the type of research was found, showing an inverse
association between female gender and publication of clinical studies (clinical studies,
OR 0.88 [95%CI 0.66–0.91]; P =0.002). In contrast, the gender gap was not associated with the research design (prospective
studies, OR 1.15 [95%CI 0.93–1.42]; P =0.18).
In the analysis of the authorship position of the female author, among clinical studies,
the percentages published by a female gastroenterologist were 1019/3097 (32.9%) for
FFA and 642/3097 (20.7%) for SFA; in preclinical studies, they were 360/1010 (35.6%)
and 245/1010 (24.3%), respectively. In the analysis of “prospective vs. retrospective”,
among prospective studies, the percentages of female gastroenterologists were 713/1942
(36.7%) for FFA and 425/1942 (21.9%) for SFA; in retrospective studies, the percentages
were 389/1144 (34.0%) and 252/1144 (22.0%), respectively.
Authorship stratified by the country of the institution
Because of the very different number of published articles coming from different countries,
the results are presented only as the percentage of FFAs and SFAs per country. The
highest percentage of FFAs was found for Brazilian institutions (9/16 articles [56.3%]).
European institutions show high percentages of FFAs (Sweden 23/49 [46.9%]; Belgium
24/53 [45.3%]; Spain 68/145 [46.9%]; the Netherlands 70/151 [46.4%]; and France 95/207
[45.9%]). The lowest percentage of FFAs was found for Japanese institutions (17/168
articles [10.1%]). For SFAs, the highest percentage reported was for Belgium (16/39
articles [41.0%]) and the lowest were for India (2/38 [5.3%]) and Japan (11/160 [6.9%])
([Table 2 ]; [Fig. 1 ]).
Table 2 Female authorship stratified by the country of the institution.
Percentage of FFAs (n/N)
Percentage of SFAs (n/N)
FFA, first female author; SFA, senior female author.
Norway
38.9 (7/18)
12.5 (3/24)
Sweden
46.9 (23/49)
18.2 (10/55)
Netherlands
46.4 (70/151)
29.1 (48/165)
Belgium
45.3 (24/53)
41.0 (16/39)
Denmark
33.3 (15/45)
31.6 (12/38)
UK
33.5 (89/266)
21.0 (57/271)
France
45.9 (95/207)
30.0 (64/213)
Germany
37.7 (83/220)
18.8 (39/207)
Switzerland
36.7 (11/30)
18.5 (5/27)
Italy
35.0 (103/294)
20.1 (57/284)
Spain
46.9 (68/145)
24.7 (39/158)
Portugal
47.1 (8/17)
33.3 (4/12)
Canada
39.5 (47/119)
33.7 (35/104)
USA
28.9 (408/1413)
19.4 (256/1320)
Brazil
56.3 (9/16)
18.8 (3/16)
Israel
26.1 (12/46)
36.8 (14/38)
China
34.5 (152/441)
24.8 (108/436)
Japan
10.1 (17/168)
6.9 (11/160)
India
20.0 (8/40)
5.3 (2/38)
Australia
31.2 (29/78)
15.5 (11/71)
Fig. 1 Percentages of first and senior female authors around the world.
Ongoing research
The number of ongoing research projects identified was 2654, split across 856 in 2020,
865 in 2021, and 933 in 2022. Stratified for the PI's gender, 1873/2654 projects (70.6%)
were directed by a male PI, 781/2654 (29.4%) by a female PI.
Of these new research projects, 2575/2654 (97.0%) were prospective studies. Among
the retrospective studies, 28/79 projects (35.4%) were directed by a female PI; among
the prospective studies, a female PI was identified in 753/2575 (29.2%). For stratification
by type of the research, 2466/2654 (92.9%) were clinical projects, with 717/2466 (29.1%)
directed by a female PI. Preclinical studies made up 185/2654 (7.0%), with 63/185
(34.1%) directed by a female PI. There was no association between female gender of
the PI and the design and type of research ([reference preclinical] clinical, OR 0.79
[95%CI 0.57–1.08; P =0.15]; [reference retrospective] prospective, OR 0.75 [95%CI 0.47–1.20; P =0.23]).
In the analysis of topics, a female PI was identified for 66/240 projects dealing
with endoscopy (27.5%), 140/493 about hepatology (28.4%), 88/255 about IBD (34.5%),
119/350 about upper and lower GI diseases (34.0%), 306/1126 about tumors (27.2%),
and 62/190 about other topics not included in previous categories (32.6%). No relationship
was found between the PI’s gender and the topic of the project in the comparison between
endoscopic vs non-endoscopic topics ([reference endoscopy] hepatology, OR 1.04 [95%CI
0.74–1.47; P =0.79]; IBD, OR 1.38 [95%CI 0.94–2.03; P =0.09]; upper/lower GI, OR 1.35 [95%CI 0.94–1.94; P =0.09]; tumors, OR 0.98 [95%CI 0.71–1.34; P =0.91]; other, OR 1.27 [95%CI 0.84–1.93; P =0.24]).
The increase in the representation of women was not equally distributed across the
world: we found countries with a significant gap in female representation compared
with others. The lowest percentages of female PIs were found in Germany (10.0%) and
Japan (11.1%), far away from the highest percentages (Portugal 66.7%, Poland 56.3%,
Spain 47.99%, and Switzerland 46.7%) ([Table 3 ]).
Table 3 Female principal investigators (PIs) stratified by the country of the institution.
Country
Percentage of female PIs (n/N)
Norway
21.4 (3/14)
Sweden
32.4 (12/37)
Netherlands
38.3 (18/47)
Belgium
38.2 (13/34)
Denmark
41.8 (28/67)
UK
32.7 (16/49)
France
39.6 (55/139)
Germany
10.0 (7/70)
Switzerland
46.7 (7/15)
Italy
16.9 (14/83)
Spain
47.9 (34/71)
Portugal
66.7 (8/12)
Canada
43.9 (18/41)
USA
33.3 (274/822)
Brazil
33.3 (3/9)
Israel
25.0 (5/20)
China
21.8 (143/655)
Japan
11.1 (2/18)
India
23.2 (13/56)
Australia
30.8 (4/13)
Discussion
This study analyzed the gender of physicians actively engaged in scientific research
in the field of gastroenterology, by assessing the relationship between the gender
of the authors of scientific papers and PIs for ongoing research. The main limitation
of this study is the lack of knowledge about the percentage composition of currently
employed gastroenterologists (i.e. the total numbers of female and male gastroenterologists).
According to the OECD (health statistic), from 2000 to 2019, the percentage of female
physicians increased from 40% to 49% [10 ] ([Fig. 2 ]). While there are no data about the percentage of female gastroenterologists across
the world as a whole, some data have been reported for a few countries, like the USA,
in which female gastroenterologists made up 17.6% in 2017 [11 ], and the UK, with 21% female gastroenterologists in 2019 [11 ]. However, these data are older than the period analyzed in our work and only partially
represent the sample under study.
Fig. 2 Change in the percentages of women in medicine over the last two decades across the
world. Source: OECD 2021 [10 ].
Nevertheless, this study reveals that, for some subspecialties and journals, there
is a higher likelihood of encountering articles published by male gastroenterologists
than by female gastroenterologists. The first part of the study focused on articles
already published, divided into editorials and original articles. An initial descriptive
analysis of the data demonstrated female representation to be 33.4% for FFAs and 21.7%
for SFAs. These data suggest a consistent trend with that reported by Long et al.
[9 ], and show a slight increase. We can speculate about this encouraging trend representing
an increase in the general representation of women in science and medicine in most
of the fields of specialization. The percentage of SFAs experienced slower growth,
which can be attributed to the longer time required for academic advancement. Female
physicians are still less inclined to choose gastroenterology as their field of residency,
perhaps owing to the long shifts; high risk operative procedures with biological and
radiological hazards limiting women’s involvement, especially during pregnancy; slow
learning curve for therapeutic procedures, which does not fit with family life; and
finally a shortage of female mentors [12 ].
The aforementioned factors could also be the reason for the differing stratification
of women’s publications on the basis of topic. In the subanalysis of topic, when compared
with publications on endoscopy, all other topics were found to have a higher likelihood
of having a female author. As previously stated, we demonstrated a higher likelihood
of publications by women in more clinically oriented issues, like hepatology, IBD,
and upper and lower GI diseases. We can speculate that these results also represent
the gender split in daily practice. Even in these clinical fields, the percentage
of SFAs remained significantly lower than the percentage of FFAs. For example, in
hepatology and articles dealing with IBD, female authors were approximately two times
(OR 2.15 and 2.12, respectively) more likely than for those about endoscopy.
It is also interesting that the association between the genders of the first and senior
authors was statistically significant: if the senior author was female, the first
author was also female in 51.4% of publications, but if the senior was a male, the
FFA rate dropped to 28.4%. These results pose a challenge in interpreting these gender-based
preferences, especially when considering that the association of FFAs and SFAs is
higher (51.4%) than the estimated percentage of female gastroenterologists involved
(17%–21%, according to the latest partial data).
Furthermore, the comparison of American and European journals showed a higher percentage
of female publications in European-based journals than in a US-based ones. To corroborate
these findings, it is notable that women practicing in European medical institutions
exhibited a higher percentage of publications than those working outside of Europe.
The highest percentages were observed in Sweden 46.9%, Belgium 45.3%, Spain 46.9%,
the Netherlands 46.4%, and France 45.9%. In addition, Brazil had a high percentage
of female publications, but these data are subject to bias from the very low number
of articles to evaluate. The lowest percentages were seen in Japan (10.1% for FFAs
and 6.9% for SFAs) and India (5.3% for SFAs). First female authorship was statistically
more frequent in European-based journals than in the US-based journals (35.6% vs.
31.4%; P =0.003); although the percentage of SFAs was higher in Group 2 than in Group 1 (22.7%
vs. 20.7%), the difference was not statistically significant (P =0.12). On the analysis of individual journals, some such as Endoscopy and GIE had percentages of FFAs and SFAs that were far below others such as Hepatology and JCC.
Editorials are typically the expression of expert opinions and the possibility of
publication is almost double for male authors (OR 1.92 [95%CI 1.58–2.33]; P <0.001).
The percentage of female PIs closely mirrored the overall proportion of FFAs (29.4%
vs. 33.1%) and significantly exceeded the overall proportion of SFAs (29.4% vs. 21.5%);
however, the association between gender and topic was not confirmed.
Efforts aimed at achieving equal opportunities for both female and male physicians
to ascend to become leaders in research are far from complete, as it is still strongly
influenced by the country in which the institution sits. This is proved by a gap of
almost 56 percentage points from the most female-inclusive country (Portugal, 66.7%
of PIs are women) to the least (Germany, 10.0% of PIs are women).
Our study presents some limitations that need to be expressed. First, the method used
to discriminate the author’s gender was based on online research via the institutional
website. Second, the absolute number of female gastroenterologists in the world and
in individual countries is not known. The selection criteria for the journals analyzed
started with the inclusion of the same journals that were evaluated by Long et al.
For the European-based journals, we chose five journals with similar IFs [9 ]. Last, we have assumed an equal impact of the SARS-COV2 pandemic on male and female
physicians in terms of scientific research.
In conclusion, this work analyzes female authorship in GI articles over a time-span
of 3 years, from 2020 to 2022. Positive signals suggesting a smooth increase in female
authorship over time came from the comparison of our results in the US-based journals
with the previous results of Long et al. for the same journals (29.3% in 2012 vs.
31.4% from 2020 to 2022). Gender biases are still present, shown by the significant
association of FFAs and SFAs, and by the correlation between the gender gap and the
design/topic of the research. Future strategies aimed at improving equity in career
development in gastroenterology should prioritize efforts to close the gap in equity
in authorship, like encouraging female mentorship and ensuring transparency during
grant selection and academic advances.
