Gender gap: surveying the world for tomorrow.

Over the last few decades, there has been a steady increase in the number and percentage of women in medicine. The number of women enrolling at medical schools currently exceeds that of men in many US and European Universities. In the oncology field, the change is reflected in the year-on-year growth in female membership of the European Society for Medical Oncology (ESMO). In 2000, women made up just 20% of ESMO members. Now, almost half of all ESMO members are women, including 54% of members under 40.

However, female representation in decision-making positions remains low. Female physicians continue to face myriad challenges in medicine ranging from implicit bias to barriers to promotion, responsibility and gaps in payment. Consequently, although an equal number of men and women now graduates from medical school, only a small fraction of female physicians become medical leaders. In academic medicine, women make up only 42% of all US medical school faculty, 24% of full professors, 17% of department or division chairs and 16% of deans.1 Women are also vastly under-represented in author, reviewer and editorial position across scientific and medical journals.2 Finally, there is also a well-documented gender disparity in the scientist-focused funding programme, start-up packages and grant application review processes.3–5 Gender bias is sometimes unconscious6 but even the use of a different level of formality when introducing a female or a male speaker may influence how people perceive expertise and competency.7

Through the Women for Oncology (W4O) Committee, ESMO aims to promote equal access to career development opportunities for female oncologists and to support them by monitoring and raising awareness about gender imbalance. An ESMO research conducted on data from 2015 to 2016 highlighted that less than half of female cancer specialists had a leadership role compared with two-thirds of their male colleagues. Only 1 in 4 board members of international oncology societies was woman and just 1 in 10 of these societies had a female president.8 A few years later, through the W4O monitoring study, we can say that women are still confined to under a third of seats on top decision-making committees.

W4O also published a survey on gender-related challenges in oncology. For the majority of respondents (women 54.6% and men 43.2%), the main barrier that prevents reaching gender parity in the oncology field is the lack of work–life balance. Men perceived as natural leaders and cultural prejudice about priority in family and domestics responsibilities were also cited as reasons for gender gap.9

In recognition of the importance of gender balance in all areas of health and medicine, ESMO keeps committed to diversity through different initiatives, including providing resources and support access to training and career development opportunities. Gender equality remains frustratingly elusive. Numerous causes have been suggested, but one argument that persists points to differences in men and women’s behaviour and roles and subsequently their societal recognition. Acknowledging existing differences and dismantling gender stereotypes are the first steps in looking for long-term solutions.

Some variables such as family, education, mentoring and role models can be especially challenging for women and influenced by local barriers. Having first-hand information about potential differences based on cultural or social pressure is key to understand why gender bias emerged and how it is perceived.

Aiming to identify local needs in the gender equity field, a series of surveys have been recently proposed by the ESMO W4O Committee to be published under the name ‘W4O in…’. These papers will be focused on differences and/or similarities in how national societies and regional organisations face gender gap and what are the local aspects strategically key for success. Given the value placed on data and evidence in cancer care and medicine in general, the impact of these interventions will be further increased by rigorous study of their effects. In the meantime, they provide valuable starting points for a problem affecting not just female physicians, but the health and performance of the systems they work in. This information will help ESMO to design, in a more effective way, future activities to motivate and to promote female oncologists’ aspirations and leadership.

The paper entitled ‘Gender climate in Indian oncology: national survey report’ is intended to be the first of this series. Bajpai et al10 launched an exploratory survey on the challenges of female oncologists in India. The aim of the study was to identify cultural obstacles and gender taboos faced by women professionals leading to a significant gender bias in the medical field. Most of the questions mirrored the 2016 ESMO W4O survey on gender-related challenges that included opinions from professionals working mainly in Europe (71.7%). In both of them, at least two-third of responding were women (61% in Indian survey, 76.7% in ESMO) and aged under 45 (69.4% and 67%, respectively). Having a woman as responsible for the team occurred in a very similar percentage of cases in both surveys (32.7% and 35.3%). In terms of challenges, the greatest barrier to career advancement for women oncologist was the balance between work and family in both of them. This concern was also identified in a survey conducted in Italy11 among young oncologists (201 participants, 67% women). Considering that 29% aged under 30 and 82% of them did not have children, the fact of facing similar barriers across regions, cultural and age differences deserves further analysis.

Academic advancement often depends on publications and reflects leadership within a profession. Several studies evaluating the proportion of women first and senior authorship over time highlighted the existing gender gap also in this field. In the series from India, Bajpai et al showed that only 26% of articles published in two leading oncology journals in India in 2017–2018 had a female lead author. This percentage is not far from a recent paper conducting a bibliometric analysis of five prominent oncology journals. Dalal et al12 demonstrated that, despite positive trends, there is still a persistent substantial gendered difference in oncology publications including 36.6% of first author and 28.5% of senior authors in 2017.

Diversity in human capital and resources can bring diversity in thought, leading to innovation, stronger teams and better outcomes for patients. Traditional conceptions of gender roles might partially shape the disparities experienced by women pursuing medical careers in each region of the world, and they need to be acknowledged and addressed. While gender gap seems to be slowly narrowing, there is still a clear room for improvement in many areas. Some of them are to increase the visibility of women, to facilitate sponsorships, mentorships and training programmes and to contribute to the awareness and correction of this inequity. New generations deserve our efforts and ESMO will be there for them.