Gender equity: Articles

Abstract
Background: Suggested anaesthetic dose ranges do not differ by sex, likely because of limited studies comparing sexes. Our objective was to systematically synthesise studies with outcomes of unintended anaesthesia awareness under anaesthesia, intraoperative connected consciousness, time to emergence from anaesthesia, and dosing to achieve adequate depth of anaesthesia, and to compare between females and males.

Methods: Studies were identified from MEDLINE, Embase, and the Cochrane library databases until August 2, 2022. Controlled clinical trials (randomised/non-randomised) and prospective cohort studies that reported outcomes by sex were included. Results were synthesised by random effects meta-analysis where possible, or narrative form.

Results: Of the 19 749 studies identified, 64 (98 243 participants; 53 143 females and 45 100 males) were eligible for inclusion, and 44 citations contributed to meta-analysis. Females had a higher incidence of awareness with postoperative recall (33 studies, odds ratio 1.38, 95% confidence interval [CI] 1.09-1.75) and connected consciousness during anaesthesia (three studies, OR 2.09, 95% CI 1.04-4.23) than males. Time to emergence was faster in females, including time to eye-opening (10 studies, mean difference -2.28 min, 95% CI -3.58 to -0.98), and time to response to command (six studies, mean difference -2.84 min, 95% CI -4.07 to -1.62). Data on depth of anaesthesia were heterogenous, limiting synthesis to a qualitative review which did not identify sex differences.

Conclusions: Female sex was associated with a greater incidence of awareness under general anaesthesia, and faster emergence from anaesthesia. These data suggest reappraisal of anaesthetic care, including whether similar drug dosing for females and males represents best care.

Anaesthesiology research has made a huge shift in sex distribution owing to the increasing number of women entering the field. This article discusses the effects of this shift on sex equality in anaesthesiology, based on scientific authorships.

Keywords: anesthesia; global health; medical education; rural health; underserved health.

Keywords: COVID-19; Women physicians; burnout; gender equity.

Keywords: Mentorship; low and middle income countries (LMICs); research; research capacity strengthening; sexual and reproductive health and rights (SRHR); women.

Keywords: Myanmar; SRHR; gender; reproductive health; war.

Abstract
Background: The representation of women among leaders in the field of anesthesia continues to trail that of their male counterparts. This qualitative study was conducted to understand the pathway of leadership acquisition among women in the field of anesthesiology.

Methods: Using constructivist grounded theory, we sought to determine whether there were specific internal or external factors that were common to women in leadership in the specialty field of anesthesiology, and specifically, how they obtained leadership positions. Semistructured interviews were conducted for data collection. A total of 26 women in leadership positions in anesthesiology participated in this study.

Results: The analysis of these interviews resulted in the development of 4 common themes related to career pathways for these women in leadership. Each theme was examined in depth to determine the qualities necessary for individuals to advance in the field and the pathway to obtaining leadership positions. The findings of this study showed that early-career, high-value mentorship and sponsorship were important factors in leadership acquisition. Most participants (n = 20; 76%) had early mentors. Of those with early mentorship, 13 (65%) had high-value mentors, who we define as someone with power or authority. Sponsorship was the leading factor contributing to leadership acquisition.

Conclusions: The results of this qualitative study may serve as a guide for encouraging female anesthesiologists with leadership aspirations. We suggest that the specialty field of anesthesiology institute targeted measures to help increase the percentage of women leadership with formal sponsorship programs at the local and national levels.

Abstract
Purpose: Although it is important to recognize gender disparities in publishing to achieve gender diversity, women's authorship in Japan remains unclear. Therefore, this study aimed to investigate the percentage and analyze the trends of articles authored and published in anesthesiology journals by Japanese female authors.

Methods: The genders of the first and last authors affiliated with Japanese institutions were surveyed in the Journal of Anesthesia (JA) (1990, 1995, and 2000-2022) and 11 international anesthesiology journals (2010-2022).

Results: We included 845 and 819 original research articles from JA in the analyses of the first and last authors, respectively. The proportion of female first authors significantly increased from 41 (11.7%) out of 351 before 2009 to 119 (24.1%) out of 494 after 2010 (p < 0.001). The proportion of female last authors was 11 (3.3%) out of 335 before 2009 and 22 (4.5%) out of 484 after 2010, respectively, with no significant difference (p = 0.470). We included 624 and 572 original research articles from international anesthesiology journals in the analyses of first and last authors, respectively. Among these, there were 134 (21.5%) and 23 (4.0%) female first and last authors, respectively. These proportions in international anesthesiology journals did not significantly differ from those in JA (p = 0.334, p = 0.789, respectively).

Conclusion: The percentage of female first authors has increased, commensurate with the percentage of female anesthesiologists. However, the percentage of female last authors has not increased and remains low in Japan.

This article is being published concurrently in Journal of Pain, PAIN, European Journal of Pain, Pain Medicine, Canadian Journal of Pain, Journal of Pain Research, Clinical Journal of Pain, and PAIN Reports. The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Citation from any of the journals can be used when citing this article.

The Presidential Address of the outgoing President of the Australian Society of Anaesthetists (ASA) was renamed the Geoffrey Kaye Oration in 1986 after the first and longest serving Secretary of the Society.1 The development of the specialty of anaesthesia in Australia benefitted from his ‘unique talents in research, teaching and organisation’, which were accompanied by his ‘dedication and capacity for hard and unremitting work’.2
On 19 January 1934, Geoffrey Kaye (1903–1986) and six other men stepped away from the Fourth Australasian Medical Congress of the British Medical Association to Hadley’s Hotel in Hobart and founded the ASA. This was undoubtedly a challenging time for the specialty but very much a cherished moment. This event created the fourth medical organisation in Australia and a split from the British Medical Association. Anaesthesia had been overlooked and not included in the initial scientific program of the Congress. This step, of forming a separate anaesthesia organisation, marked in Australia that anaesthesia, ‘for so long merely the handmaiden of surgery, was now itself a science and an art and for its practice there must be training and teaching’ and it would be the newly formed ASA which would steer this course.2
Since that day in 1934, the Annual General Meeting of the ASA has almost always been held in conjunction with the National Scientific Congress (NSC). Annual General Meetings and Congresses mark time for organisations such as ours. Whilst reflecting on the Congresses that have marked my time as President, there are two moments that I would like to share with you today.
The first is the 2019 NSC in Sydney, convened by Dr Anne Jaumees. During the NSC a colleague asked me what number female President of the ASA I would be. As I had been in an Acting President role for a good part of the year, I was embarrassed that I didn’t know the answer, but I quickly looked it up. Five. I am the fifth woman to be President of the Australian Society of Anaesthetists and the 46th President.

Background: Historically in medicine, women and minorities have been underrepresented. This trend is especially significant in the anesthesiology workforce.

Objective: The goals of this study were to quantify the current state of diversity by race/ethnicity, gender, and sexual orientation among anesthesiology residents.

Methods: An institutionally reviewed and validated survey was delivered through Qualtrics to 130 anesthesiology program directors. Topics addressed included gender identity, sexual orientation, racial and ethnic background, rationale for pursuing anesthesiology, and medical training experiences. The study was administered from February to April 2021; 135 anesthesiology residents responded to the survey.

Results: The sample was 44.4% white (n = 60), 54.1% male (n = 73), and 83.7% (n = 113) of respondents self-reported as straight or heterosexual. Respondents indicated that role models/mentors were somewhat or very important in their desire to pursue anesthesiology (n = 85; 67.2%), 42% reported that having women/diverse faculty was somewhat or very important in their decision to pursue anesthesiology. Discrimination during the anesthesiology residency application process or as a resident ranged from 4.4% due to sexual orientation to 18.7% due to gender/gender identity and race/ethnicity.

Conclusions: Experiences of discrimination based on race/ethnicity, gender, and gender identity continues to be a concern among anesthesiology trainees. Creating an environment that is inclusive and supportive of all trainees regardless of race/ethnicity, gender/gender identity, and sexual orientation is needed. Interventions and strategies to create an inclusive environment may improve diversity within anesthesiology.

As the field of anesthesiology evolves and grows, so does the important role women play in its ongoing success and development. The ASA Monitor had the privilege of speaking with three women whose leadership and expertise have had – and continue to have – a positive impact on anaesthesiology and medicine as a whole.

Abstract
A survey carried out by the Australian Society of Anaesthetists explored gender issues in the personal and professional lives of anaesthetists. Issues highlighted include training and career paths, combining anaesthetic training with domestic responsibilities, personal relationships, pregnancy and childrearing, private practice, part-time work, parental leave, the single anaesthetist, doctor spouses, sexual harassment, and negative attitudes in colleagues. Particular problems were identified in the training years, in part-time work, in private practice, and in combining parental and domestic responsibilities with a career in anaesthesia. Strategies to address relevant issues are discussed, with reference to the increasing proportion of women in medicine and anaesthesia.

Background: Although there has been a considerable increase in the representation of women in medicine, a gender gap still exists with regard to leadership positions. This gender discrepancy has been identified in the field of anesthesiology, in terms of first and senior authorship, as well as in general composition of editorial boards in Anesthesiology and Anesthesia & Analgesia. The goal of this study is to examine the current representation of women in editorial boards of anesthesia journals with respect to the hierarchy of different editorial positions and to assess whether there has been improvement toward equity in recent years.

Methods: A comprehensive search was performed for anesthesiology journals indexed in the Scimago Journal and Country Rank in May 2020. The editorial boards of the top 20 journals by impact factor were analyzed. Editorial board members were categorized based on their title. Gender was assigned using images or pronouns on research databases or hospital-affiliated websites. The percentage of women within each category was calculated. When available, the year the editors obtained their medical degree was collected. A binomial proportion test was used to analyze the distribution of women overall and among editorial roles, compared to the proportion of women anesthesiologists (26%). A Wilcoxon rank-sum test was used to compare time since medical degree between genders. Additionally, women representation in anesthesiology editorial boards in 2020 was compared to 2010.

Results: A total of 19 journals were included in this study, as 1 journal did not disclose editorial board membership. Overall, women occupied 18% of all editorial board positions. All editors-in-chief and assistant/associate/deputy editors-in-chief were men. Women consisted of 17.1% of executive/section/senior editors, 17.9% of editors, and 20.6% of associate/assistant editors. There were significantly fewer women editorial board members than the percentage of women anesthesiologists (18% vs 26%; P < .001). Editorial boards from 2010 were available for 14 journals, and of these journals, women comprised 12% of editorial board members in 2010 compared to 19% in 2020 (P = .001).

Conclusions: These findings suggest that in anesthesiology journals, women are underrepresented at all editorial levels, especially at higher levels. As editorial boards have a significant impact on which articles are published by a journal and thereby significant influence on the specialty as a whole, the lack of gender equity in editorial boards should be addressed.

Editor—Previous analyses have described a gender gap in authorship in the anaesthesiology literature.1, 2, 3, 4, 5 However, there is a lack of recent data to determine if the gender gap is improving in the current era. We sought to update the literature on the topic; we also aimed at identifying factors associated with woman authorship as compared with man authorship.

For this purpose, we evaluated the prevalence of woman first author and last author in articles published from 2008 to 2018 in the five general anaesthesia journals with the highest 2018 impact factor (excluding subspecialty journals).

Despite increasing numbers of women entering anaesthesia, they remain persistently under-represented within academic anaesthesia and research. Gender discordance is seen across multiple aspects of research, including authorship, editorship, peer review, grant receipt, speaking and leading. Women are also under-represented at higher faculty ranks and in department chair positions. These inequities are further magnified for women with intersectional identities, such as those who identify as Black, indigenous and women of colour. Several barriers to participation in research have been identified to date, including a disproportionate amount of family responsibilities, a disproportionate burden of clinical service, gender bias, sexual harassment and the gender pay gap. Several strategies to improve gender equity have been proposed. Increasing access to formal mentorship of women in academic medicine is frequently cited and has been used by healthcare institutions and medical societies. Senior faculty and leaders must also be conscious of including women in sponsorship and networking opportunities. Institutions should provide support for parents of all genders, including supportive parental leave policies and flexible work models. Women should also be materially supported to attend formal educational conferences targeted for women, aimed at improving networking, peer support and professional development. Finally, leaders must display a clear intolerance for sexual harassment and discrimination to drive culture change. Peers and leaders alike, of all genders, can act as upstanders and speak up on behalf of targets of discrimination, both in the moment or after the fact. Gender inequities have persisted for far too long and can no longer be ignored. Diversifying the anaesthesia research community is essential to the future of the field.

Physician burnout and poor mental health are prevalent and often stigmatised. Anaesthetists may be at particular risk and this is further increased for women anaesthetists due to biases and inequities within the specialty. However, gender-related risk factors for and experiences of burnout and poor mental health remain under-researched and under-reported. This negatively impacts individual practitioners, the anaesthesia workforce and patients and carries significant financial implications. We discuss the impact of anaesthesia and gender on burnout and mental health using the COVID-19 pandemic as an example illustrating how women and men differentially experience stressors and burnout. COVID-19 has further accentuated the gendered effects of burnout and poor mental health on anaesthetists and brought further urgency to the need to address these issues. While both personal and organisational factors contribute to burnout and poor mental health, organisational changes that recognise and acknowledge inequities are pivotal to bolster physician mental health.

Keywords: confidence gap; gender bias; medical education; teaching; unconscious bias.

Abstract
Fellowships are competitive training posts, often in a subspecialty area. We performed a quality assessment of potential interviewer bias on anaesthesia Fellow selection. After research locality approval, we analysed interview scores for all Fellowship applications to our department over six years. Panel interviewers participated in a structured interview process, asking a series of standardised questions to rate applicants. A mixed model analysis of total applicant rating with crossed effects of applicants and interviewers was used. A total of 94 applicants were interviewed by 27 panel members, with between two and four panel members per interview, giving a total of 329 applicant ratings. The random effect of applicants accounted for 45.8% of total variance in ratings (95% confidence intervals (CI) for intraclass correlation (ICC) 35.8%-57.2%) while interviewer effects accounted for 13.4% of total variance (95% CI for ICC 5.3%-30.0%). We found no evidence of bias for most potential sources after analysing multiple applicant and interviewer factors. After adjusting for interviewer training programme, applicants from other training programmes were rated a mean of 1.87 points lower than Australian and New Zealand College of Anaesthetists (ANZCA) applicants (95% CI 0.62-3.12, P = 0.003) and 1.84 points lower than Royal College of Anaesthetists (RCoA) applicants (95% CI 0.37-3.32, P = 0.014). After adjusting for applicant gender, female clinicians rated applicants 1.12 points higher (95% CI 0.19-2.06, P = 0.019) on average than male clinicians. The observed differences in interview scores amongst male and female clinicians and lower scores in applicants from programmes other than ANZCA/RCoA were small, and require confirmation in independent studies.

Abstract
Animal model research is insufficient to guide the application of novel therapies in human patients, but the same objections should apply to human trials which do not representatively sample sexes in the population. Female participants have historically been excluded from anaesthesia research due to concerns of potential teratogenicity and unfounded apprehension that female hormones would interfere with the physiologic processes under examination. Consequently, many drugs currently available on the international market have not been thoroughly tested in female patients. The representation of intersex individuals in anaesthesia research, moreover, is exceedingly rare. An increasing awareness of these disparities in recent decades has led to the recognition of biological sex as an important pharmacodynamic variable, and the prospect that clinical decision-making in anaesthesia can be informed by known sex differences in the sensitivity to anaesthetics, the risk of adverse drug reactions, and the distribution and excretion of agents used to induce and maintain anaesthesia. Despite this, sex representation in anaesthesia research remains poorly regulated and sex-specific data are often reported in aggregate. Greater formal recognition of sex differences in study protocols and practice guidelines is warranted to meaningfully and incrementally improve anaesthesia care for female and intersex patients.

nternational Women’s Day celebrates women’s achievements and raises awareness of the continuing mission towards gender equality. So it’s a good time to be reminded we still need to correct decades — centuries even — of gender bias in medicine and medical research.

It’s no secret men and women are different. It’s why we have a whole genre of books and jokes about why “men are from Mars and women are from Venus”.

Mentally, physically and biologically, men and women are simply not built the same way. It sounds obvious, but we have only really begun to understand why.

These differences have not been reflected accurately in the field of medicine. Women’s health has too often been considered a niche area — even though it involves roughly 50% of the world’s population.

A recent study published in the Proceedings of the National Academy of Sciences concluded that women are more likely to take COVID-19 seriously — and more likely to comply with public health recommendations like mask wearing and social distancing. The researchers surveyed more than 21 000 individuals across eight different countries last March and found that 59% of female respondents considered COVID-19 to be a very serious health problem, compared with just 49% of men. Women were also 6 percentage points more likely to agree with proposed social distancing measures.

Abstract
Background: Uncovering patients' biases toward characteristics of anesthesiologists may inform ways to improve the patient-anesthesiologist relationship. The authors previously demonstrated that patients prefer anesthesiologists displaying confident body language, but did not detect a sex bias. The effect of anesthesiologists' age on patient perceptions has not been studied. In this follow-up study, it was hypothesized that patients would prefer older-appearing anesthesiologists over younger-appearing anesthesiologists and male over female anesthesiologists.

Methods: Three hundred adult, English-speaking patients were recruited in the Preanesthesia Evaluation and Testing Center. Patients were randomized (150 per group) to view a set of four videos in random order. Each 90-s video featured an older female, older male, younger female, or younger male anesthesiologist reciting the same script describing general anesthesia. Patients ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member. Patients also chose the one anesthesiologist who seemed most like a leader.

Results: Three hundred patients watched the videos and completed the questionnaire. Among patients younger than age 65 yr, the older anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.92; 95% CI, 1.41 to 2.64; P < 0.001) and more intelligent (odds ratio, 2.24; 95% CI, 1.62 to 3.11; P < 0.001), and had greater odds of being considered a leader (odds ratio, 2.62; 95% CI, 1.72 to 4.00; P < 0.001) when compared with younger anesthesiologists. The preference for older anesthesiologists was not observed in patients age 65 and older. Female anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.46; 95% CI, 1.13 to 1.87; P = 0.003) and more likely to be chosen to care for one's family member (odds ratio, 1.80; 95% CI, 1.40 to 2.31; P < 0.001) compared with male anesthesiologists. The ranking preference for female anesthesiologists on these two measures was observed among white patients and not among nonwhite patients.

Conclusions: Patients preferred older anesthesiologists on the measures of confidence, intelligence, and leadership. Patients also preferred female anesthesiologists on the measures of confidence and likelihood of choosing the anesthesiologist to care for one's family member.

Keywords: Gender equity; anesthesiology; feminist; gender discrimination; implicit bias; leadership; qualitative research.

Keywords: academia; anaesthesia; awards; gender equality; gender equity; leadership; women in medicine.

Keywords: anaesthesiology; gender bias; implicit bias; leadership; promotion; residency training; women in medicine.

Keywords: European Society of Anaesthesiology; anaesthesia; career development; gender; leadership; survey; women.

Keywords: confidence gap; gender bias; medical education; teaching; unconscious bias.

Keywords: anaesthesia; gender; randomised trial; research; sex.