The WOMEDS project collects primary information, not always public, and elaborated indicators to quantify the gender bias in medicine in Spain with the aim of establishing an observatory to monitor its evolution over time. In this article, we presented the project, whose data and indicators are openly accessible through the project web https://womeds.es, and the initial results. We defined and calculated indicators, which have been grouped into four areas: the practice of the medical profession (healthcare), the presence of women in visible and relevant positions in scientific and professional organizations, women in academia (positions in universities) and research (publicly funded projects). Where possible, indicators are disaggregated by medical specialty and by region.
Our study showed a pronounced gender gap in medicine in Spain in all four settings. These results corroborate prior data highlighting that generalized access to the medical profession by women has not translated into adequate integration of women into leadership positions in health care, in medical councils and associations, in medical congresses, as well as in academic career and research (in terms of project’s acceptance and funding).
Empowerment and visibility of women in healthcare in public centers is the exception in Spain and changes are very slow. High work positions, such as head of department and head of section are mainly held by men, not following the female representation in hospitals and health centers.
No systematic patterns of feminization of leadership positions or the opposite are found across specialties, although the information we had only included 7 AACC in this first report. Only preventive medicine and public health present a clear advantage for female leadership, and a few specialties (neurosurgery, pneumology, and clinical neurophysiology) have WRs greater than or equal to 1 in three AACCs analyzed. The great variability between AACCs in the WRs of the top positions points to where to advance. Benchmarking is possible: in one AACC (i.e., Navarra), there is no evidence of gender bias in the top positions. Navarra could, therefore, be a case study from which other AACCs could learn. Is Navarra doing differently as for filling the positions of healthcare leadership? Surgical specialties have less participation of women, and half of the specialties with low women empowerment (no heads of department women in at least 3 out of 7 AACCs considered) are surgical.
Surgical specialties have less participation of women, and half of the specialties with low women empowerment (no heads of department women in at least 3 out of 7 AACCs considered) are surgical. The entry of women into specialties traditionally considered more attractive to men could be negatively influenced by the recent changes in the medical residency selection process [27].
Investigating the gender presence in national medical congresses, only 3 medical societies (out of 36 Spanish societies providing data from annual congress held in the study period) report a WR greater than one for women speakers. Only 4 societies reported a WR > 1 for women in the scientific committee. That shows an evident inequality. Only 3 medical associations in Spain had a female president during the whole period 2019–2021. Data published by international societies such as the European Society of Medical Oncology are similar, highlighting that invited speakers at International/National oncology congresses were significantly less likely to be female than male or that board members of International/National oncology societies were significantly less likely to be female than male (P < 0.001; 26.8% in 2016 to 35.8% in 2019). Interestingly, Societies with a female president had a higher proportion of female board members across these periods [28].
We also found a gender gap against women in the top leadership and institutional representation positions in province official colleges of physicians, academies of medicine, and universities. A man as president, a woman as vice-president or secretary, is a common picture in most medical organizations. These results are in line with evidence that emerged worldwide [3, 5, 29–33] as well as in Spain [16, 19–22].
The situation in universities is worrying with a with a striking lack of women in leadership positions. Furthermore, we found a gender gap in the applications to research projects of the ISCIII with fewer applications submitted by women as well as in the success rate and average funding received. There is evidence of this bias worldwide [34]. Moreover, according to a recent study, this could also explain the gender gap in female first authorship manuscripts in scientific fields [11]. This inequality found in Spain leads us to propose active policies of positive discrimination in the calls for research projects in medicine, in line with Alvarez and colleagues [35], who proposed the following recommendation for funders in order to promote gender equity in grantmaking: to describe the ideal candidate in non-gendered terms in requests for grant proposals and reviewer guidelines, to challenge institutions to take a close look at possible gender inequities (e.g. salaries) and to ask recommenders to address an applicant’s objective research record and avoid references to personal circumstances that are irrelevant to the award.
Following the results obtained, the need to propose measures and interventions aimed at lifting barriers and reducing bias, within a defined time horizon is evident. Such measures must concern all levels of government, from state or regional regulation to changes in organizational culture or incentives in specific organizations.
Recently, Knoll and colleagues were suggesting some proactive efforts such as the requirement of minority candidates at least being included among a pool of candidates for a leadership position to avoid gender bias in high-ranked work positions [36]. Improving diversity in senior positions is important for many reasons, and one key reason is to provide the role models needed to encourage the increasingly diverse student body entering medical faculty today [33].
Thanks to the #LancetWomen initiative, which called for papers reporting original research, analysis, and commentary to help create a set of transformative explanations and actions [37], followed a very interesting issue that analyzed the representation, experience, and promotion of women in science, medicine, and global health, hypothesizing its causes and solutions. Kang and Kaplan proposed five strategies for moving toward gender diversity and inclusion in medicine, suggesting focusing on more comprehensive interventions that address structural and systemic changes instead of targeting individual attitudes and behavior [38]. Those concerned treat gender equality as an innovation challenge, change institutional norms, create a culture in which people feel personally responsible for the change, implement behavioral guidelines and action plans as well as create organizational accountability for change.
The visibility of women doctors in the top positions of medical organizations is limited. There is a common pattern in many areas of analysis, be they scientific societies, professional associations, university medical schools: the visible head and institutional representative is a man (president, dean), and in his team, there are women occupying lower-ranking positions (vice-president, committee members, etc.). This specific bias is very pronounced and persistent. We found that women have a lower probability of being granted, and if so, they get less money for projects. An important objective of this study is to make the problem visible and thus contribute to solving it. In fact, the completion of the questionnaires was instrumental in making some societies and institutions aware of the gender gap for the first time.
The study has some strengths and limitations. Among the strengths, this is the first comprehensive study containing primary and recent data concerning various aspects of medical professions in Spain. This allowed us to report an exhaustive scenario of gender bias in medicine in Spain. There are no similar studies published; most papers are focused on specific areas (for instance, women in the academy) or one specific specialty but they did not cover all the angles (clinical practice, research, academia, and management) and different specialties at the same time.
Among the limitations of this study, we did not have historical data. Thus, it did not allow us to study the evolution of this phenomenon. Anyway, within the WOMEDS aims, there is the intention to continue collecting annually all these primary data to monitor the evolution over time of gender bias in the medical profession in Spain and, hopefully, evaluate the success of the measures implemented. Another limitation is that we do not have some relevant information (such as age and ethnicity). Is well known that age could play an important role in career advancement, while the disadvantage is multiplied by the intersection of gender with race, ethnicity, caste, or religion – depending on where you are in the world [3]. Of course, it could be relevant to also collect this information within the WOMEDS project, in order to both control and study these variables. An additional limitation is the potential bias linked to the sources of information, at least the medical specialties ones. Also, the granularity and detail of the responses were different among medical societies. The research data collected only covers one program by now. We expect to enlarge the WOMEDS project with complementary indicators and new collaborators willing to join the project to publicly share their own data to analyze gender bias and its evolution over time.