Gender sensitivity and stereotypes in medical university students: An Italian cross-sectional study.

Gender medicine is crucial to reduce health inequalities. Knowledge about students' attitudes and beliefs regarding men, women and gender is important to improve gender medicine courses. The aim of this study is to evaluate gender stereotypes and its predictors in Italian medical students. We performed an online cross-sectional study among students from the University of Turin. We used the validated Nijmegen Gender Awareness Scale in Medicine scale to explore gender sensitivity and stereotypes. Multivariable logistic regression model was performed to explore potential predictors of gender awareness. We enrolled 430 students. Female sex, a better knowledge on gender medicine and having had a tutor aware of gender issues are associated with higher gender sensitivity. Older age, a better knowledge on gender medicine and having had a tutor sensitive to gender issues were predictors of more stereotyped opinions towards patients. Having had a tutor aware of gender medicine, male sex and older age were associated with more stereotypes towards doctors. Italian students have high gender sensitivity and low gender stereotypes. Age, higher knowledge of gender medicine and having had a tutor that considered gender were associated with higher gender stereotypes. Focusing on gender awareness in medical schools can contribute to a better care.

Introduction

Gender medicine is a transversal dimension of medicine, which describes within the same disease the differences of symptoms, clinical evolution, drug therapy and prevention between men and women. The goal of gender medicine is to understand the mechanisms through which gender differences influence health, the onset and course of many diseases and the outcomes of therapies [1-3]. For example, during clinical practice, gender of doctors and patients influences medical communication, patients’ symptom presentations [4,5] and interpretations of patients’ complaints and signs [6,7].

A Danish study with a sample of 6.9 million patients, reports that women receive a diagnosis of disease 4 years later than men [8]. Another study reports that the in-hospital mortality of an acute myocardial infarction (AMI) is higher in women than in men up to 70 years of age and survival after 6 months of AMI is lower in women [9].

In many diseases, such as coronary artery disease, Parkinson disease, irritable bowel syndrome, neck pain, knee joint arthrosis and tuberculosis, men are treated more extensively than women [10]. Research found that physicians are more likely to consider symptoms reported by men as organic [10]. These differences, if not properly considered, can lead to health inequality. In particular, some pathologies can be undertreated in women compared to men or vice versa. For this reason, it is important that doctors are aware of gender differences during their clinical practice. The World Health Organization defines gender awareness as an ‘understanding that there are socially determined differences between women and men based on learned behaviour, which affect their ability to access and control resources’ [11]. However, medical phenomena are often both social and biological [12]. Gender awareness in doctors aims to equity and equality in health. Nevertheless, in the past, gender was not considered in medicine. Firstly, in the past medicine was ‘gender blind’. Secondly, medicine seems to be ‘male biased’ because the largest body of knowledge on health and illness is about men and their health. Thirdly, gender role ideology leads to wrong diagnosis and treatment. Gender equity is not a spontaneous process. Gender medicine teaching may contribute to improve gender knowledge. Implementation of gender medicine as a qualitative investment in medical education is important for a future better health [13]. Gender awareness includes three components: gender-sensitivity, gender-role ideology and knowledge [14]. Gender sensitivity is the ‘ability to perceive existing gender differences, issues and inequalities and incorporate these into strategies and actions’ [11]. Gender sensitivity includes the awareness that gender has an impact on health, and affects the presentation of health complaints. This sensitivity allows healthcare professionals to effectively address gender and improve care for both men and women [15]. Gender-role ideology represents a health care worker’s attitude towards male and female patients and doctors [16]. Furthermore gender-role ideology is present at different levels in health services. Gender role ideology towards patients are a risk factor for inadequate care. For example, several studies show that doctors often attribute psychological symptoms to women for the same symptoms reported [17]. Gender role ideology towards doctors instead refer to false beliefs such as thinking that female doctors are more empathic than male doctors [18]. Gender awareness is important to prevent gender bias, to reduce health inequalities and to improve ‘patient-centered medicine’. Gender bias includes gender stereotype (unjustified difference of treatment between female and male patients) and gender blindness (inability to recognize differences when they are clinically pertinent).

Measuring medical students’ attitudes and values concerning gender is possible using the Nijmegen Gender Awareness Scale in Medicine, (N-GAMS). A Netherlands study shows that male medical students held stronger gender stereotypes than female [1]. A Swedish study found difference in gender sensitivity and gender -role ideology between Dutch and Swedish student. Male students had more gender stereotypes than female. Age, father’s birth country and mother’s education level had impact on gender sensitivity and stereotypes [19]. Another study conducted in Portugal on medical students showed that empathy was associated with higher gender sensitivity and lower endorsement of gender-role ideologies, while sexism was associated to higher endorsement of gender-role ideologies and lower gender sensitivity [20]. In Switzerland, data from a observational study suggests a more gender stereotyped opinion toward patients among male students; in addition, gender sensitivity increase while stereotypes decreased with students getting older [21]. The focus on a medicine that takes gender differences into account begins in the 80s with the signing by the UN (United Nation) of a convention aimed at eliminating all forms of discrimination against women [22]. In Europe, a growing interest in gender medicine led to the inclusion of this issue in the new Horizon 2020 research funding program [22]. In Italy, a Plan for the application and diffusion of Gender Specific Medicine (2019) aims to spread the principles of gender specific medicine that are not yet fully and adequately implemented in medical academic training [22]. For this reason, the aim of this study is to evaluate gender awareness through N-GAMS scale and its predictors in Italian male and female medical students, since no data exist in literature about gender awareness in our national context.

Materials and methods

We performed an online cross-sectional survey among medical students of the University of Turin during March 2020. Students of the fifth and sixth years and outside prescribed time were considered eligible for this study. The questionnaire was submitted to students of the last years of the degree course because they already had practical training experiences with patients and had received an important part of theoretical training. All students were recruited and no one was excluded on the basis of gender, age or nationality. A sample of 1258 students received an email with the background, purpose of the study and the link to the online questionnaire. Informed consent was requested. Participation in the study was voluntary and anonymous. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Internal Review Board of the Department of Public Health Sciences, University of Turin.

The questionnaire

After a review of the literature, a 29-items questionnaire was developed, organized in five sections:

Socio-demographic characteristics of the sample (items 1–9);

Knowledge about gender medicine issues (items 10–13);

Attitudes of the students regarding gender medicine (items 14–19);

Gender sensitivity and stereotypes toward patients and doctors (item 20), using the validated questionnaire developed by Verdonk et al., the Nijmegen Gender Awareness In Medicine Scale (N-GAMS) [1];

Training experiences regarding gender medicine (items 21–29).

The questionnaire was in Italian-language. A bilingual researcher translate the tool from English to Italian. The translated N-GAMS scale was then tested for understandability in a pilot study recruiting 20 medical students.

This paper focuses on the fourth part of questionnaire, assessing gender sensitivity and gender stereotypes in medical students and their association with socio-demographic features, gender medicine knowledge and training experience regarding gender medicine.

Table 1 displays the variables assessed to describe the sample, stratified by gender. In particular, we explored the following characteristics: age, year of course, nationality, marital status, having children, self-perceived health status, having one or more chronic diseases, familiarity for chronic diseases. Self-perceived health status was assessed with a Likert scale, ranging from 1 (very bad) to 5 (very good), and it was subsequently dichotomized in “not good” (score 1 and 2) and “good/very good” (score 3, 4 and 5). Gender medicine knowledge was assessed with questions regarding the correct definitions of sex, gender and gender medicine, gender-related epidemiology of frequent diseases, and true/false questions regarding specific gender medicine issues.

Table 1

Description of the sample (N = 430).

		Females % (N)	Males % (N)	p-value
Age	Mean±SD	25.20±2.26	25.11±1.86	0.689
Year of Course	Fifth	41.16 (121)	46.67 (63)	0.445
	Sixth (last)	31.29 (92)	31.11 (42)
	Outside prescribed time	27.55 (81)	22.22 (30)
Nationality	Italian	98.98 (291)	99.26 (135)	0.623
	Other	1.02 (3)	0.74 (1)
Marital Status	Single	86.99 (254)	93.38 (127)	0.032
	With Partner	13.01 (38)	6.62 (9)
Children	No	99.66 (293)	100.00 (135)	0.685
	Yes	0.34 (1)	0.00 (0)
Health Status self-reported	Not good	14.29 (42)	11.76 (16)	0.291
	Good / Very Good	85.71 (252)	88.24 (120)
Chronic Diseases	No	85.71 (252)	88.97 (121)	0.222
	Yes	14.29 (42)	11.03 (15)
Familiarity for Chronic diseases	No	27.21 (80)	27.94 (38)	0.616
	Yes (parents / brothers /sisters)	68.37 (201)	69.85 (95)
	Yes, other relatives	4.42 (13)	2.21 (3)
Knowledge about Gender Medicine	Poor (under the mean of the sample)	41.84 (123)	62.50 (85)	<0.001
	Good (equal or above the mean of the sample)	58.16 (171)	37.50 (51)
Have you ever dealt with gender medicine issues during lessons? Answer: Yes		62.24 (183)	71.32 (97)	0.041
During traineeships in the wards, did you ever discuss with the tutor about the impact of sex and gender on patient management? Answer: Yes		24.23 (71)	41.04 855)	<0.001
During the traineeships in the wards, did you have the impression that the tutor took into consideration sex and gender of patients during clinical practice? Answer: Yes		40.61 (119)	44.70 (59)	0.247

Personal experience during academic training were assessed asking the students whether they have dealt with gender medicine issues during lessons and during traineeships in the wards.To measure student’s gender awareness, we used the N-GAMS scale. This scale explores two attitudinal aspects of gender-awareness: gender sensitivity (GS) and gender role ideology towards patients (GRIP) or doctors (GRID). We asked the students to self-report their agreement for each item, on a Likert scale ranging from 1 “not agree at all” to 5 “totally agree”. Some sentences have reverse meaning; therefore, in these cases we calculated a reverse score. The GS score has 14 items, which investigate student’s general opinion of considering gender and sex in healthcare; the GRIP score has 11 items, which explore the presence of stereotypes about male or female patients; the GRID score has 7 items, which investigate student’s stereotypes towards practice of doctors. A higher GS score means a higher gender sensitivity. GRIP and GRID high score indicates more gender-stereotyping opinions. In this paper, concerning gender awareness and their predictors, we consider as outcome N-GAMS (the fourth part of the questionnaire).

Statistical analysis

Descriptive analyses were carried out for all the variables. The continuous variable (age) was expressed as mean and standard deviation (SD). All the other variables were reported as percentages and numbers for each category. To evaluate differences between groups defined by the gender, Fisher’s exact tests were calculated. Potential predictors of gender awareness were explored through a multivariable logistic regression model. The covariates to be included into the model were selected using a stepwise forward selection process, with a univariate p<0.25 as the main criterion. Missing values were excluded by listwise deletion. All analyses were performed with the STATA 13 software, and a two-tailed p-value <0.05 was considered to be statistically significant.

Results

Socio-demographic characteristics

A sample of 430 students completed the questionnaire correctly. Females students were 294 (68.4%) and 136 (31.6%) were males. Sample mean age was 25.2±2.1. The 42.9% of the students attended fifth year of medical school, while the others were divided between sixth year and outside prescribed time. The knowledge about gender medicine is significantly different between male and female students (p<0.05).

The 41.8% of female students and 62.5% of male students had a poor knowledge of gender medicine (under the mean of the sample). There was a significant difference between males who reported having dealt gender medicine during lessons (71.3%) and females (62.2%) as well as during traineeships in the wards. Only about half of the sample had the impression that their tutor took into consideration sex and gender of patients during clinical practice. (Table 1).

Stereotypes in gender medicine

A significant difference between male and female students was found with the GS sub-scale, with a mean score of 3.86±0.41 for female and 3.73±0.41 for male (p = 0.003). This suggests that female students had higher sensitivity to gender issues. As shown in Table 2, GRIP (the higher the score value the stronger the stereotypes toward patients) subscores were not significantly different between female and male students (1.80±0.57 for women, 1.87±0.65 for men). GRID subscore, instead, significantly differs between males (1.64±0.68) and females (1.51±0.49) which suggests that male students have significantly more stereotyped opinion toward doctors than females (p = 0.028) (Table 2).

Table 2

Stereotypes in gender medicine: Gender sensitivity (GS), role ideology toward patients (GRIP) and role ideology towards doctors (GRID).

		Females	Males	p-value
Gender Sensitivity (GS)	Mean±SD	3.86±0.41	3.73±0.41	0.003
Gender Role Ideology toward Patients (GRIP)	Mean±SD	1.80±0.57	1.87±0.65	0.263
Gender Role Ideology toward Doctors (GRID)	Mean±SD	1.51±0.49	1.64±0.68	0.028

Potential predictors of GS, GRIP and GRID

We used a multivariable linear regression model to explore whether the socio-cultural background variables were related to outcome on GS, GRIP and GRID. Males had lower GS scores (coefB -0.96, CI95% -0.18 - -0.01, p-value = 0.030), while students who had a better knowledge on gender medicine (coefB 0.14, CI95% 0.0 6–0.22 p-value <0.001) and those who have received good example from the internship tutors (coefB 0.14, CI95% 0.06–0.26 p-value <0.001) were more gender-sensitive. (Table 3). Moreover, older students expressed more stereotypical thinking about patients (coefB 0.04, CI95% 0.01–0.07 p-value = 0.012). Surprisingly, students who had a better knowledge of gender medicine (coefB 0.12, CI95% 0.01–0.24 p-value = 0.040) and those who had the impression that their tutor took into consideration sex and gender of patients during clinical practice (coefB 0.13, CI95% 0.01–0.25 p-value = 0.045) agreed more with stereotypical thinking about patients (Table 4).

Table 3

Potential predictors of gender sensitivity.

		Coef B	CI95%	p-value
Age		0.01	(-0.01–0.03)	0.400
Sex	Female	Ref	-	-
	Male	-0.96	(-0.18 - -0.01)	0.030
Year of Course	Fifth	Ref	-	-
	Sixth or more	0.02	(-0.03–0.07)	0.531
Marital Status	Single	Ref	-	-
	With partner	-0.07	(-0.20–0.07)	0.327
Health Status self-reported	Poor	Ref	-	-
	Good / Very good	-0.01	(-0.13–0.11)	0.875
Chronic Diseases	No	Ref	-	-
	Yes	-0.07	(-0.19–0.05)	0.232
Familiarity for Chronic diseases	No	Ref	-	-
	Yes	-0.01	(-0.06–0.09)	0.707
Knowledge about Gender Medicine	Poor	Ref	-	-
	Good	0.14	(0.06–0.22)	<0.001
Have you ever dealt with gender medicine issues during lessons? Answer: Yes		-0.08	(-0.16–0.00)	0.050
During traineeships in the wards, did you ever discuss with the tutor about the impact of sex and gender on patient management? Answer: Yes		-0.01	(-0.10–0.08)	0.813
During the traineeships in the wards, did you have the impression that the tutor took into consideration sex and gender of patients during clinical practice? Answer: Yes		0.14	(0.06–0.26)	<0.001

Table 4

Potential predictors of gender role ideology towards patients (GRIP).

		Coef B	CI95%	p-value
Age		0.04	(0.01–0.07)	0.012
Sex	Female	Ref	-	-
	Male	0.04	(-0.08–0.17)	0.490
Year of Course	Fifth	Ref	-	-
	Sixth or more	-0.07	(-0.15–0.01)	0.053
Marital Status	Single	Ref	-	-
	With partner	-0.04	(-0.24–0.15)	0.669
Health Status self-reported	Poor	Ref	-	-
	Good / Very good	0.05	(-0.13–0.22)	0.593
Chronic Diseases	No	Ref	-	-
	Yes	0.03	(-0.14–0.20)	0.740
Familiarity for Chronic diseases	No	Ref	-	-
	Yes	-0.07	(-0.18–0.05)	0.242
Knowledge about Gender Medicine	Poor	Ref	-	-
	Good	0.12	(0.01–0.24)	0.040
Have you ever dealt with gender medicine issues during lessons? Answer: Yes		0.12	(0.01–0.24)	0.050
During traineeships in the wards, did you ever discuss with the tutor about the impact of sex and gender on patient management? Answer: Yes		0.06	(-0.08–0.20)	0.045
During the traineeships in the wards, did you have the impression that the tutor took into consideration sex and gender of patients during clinical practice? Answer: Yes		0.13	(0.01–0.25)	0.045

Gender stereotypes towards doctors were higher in male students (coefB 0.12, CI95% 0.01–0.24 p-value = 0.046) and with increasing age (coefB 0.03, CI95% 0.01–0.06 p-value = 0.045). Having a tutor that took into consideration sex and gender of patients during clinical practice was associated with more stereotypical thinking about doctor (coefB 0.03, CI95% 0.01–0.06 p-value = 0.045) (Table 5).

Table 5

Potential predictors of gender role ideology towards doctors (GRID).

		Coef B	CI95%	p-value
Age		0.03	(0.01–0.06)	0.045
Sex	Female	Ref	-	-
	Male	0.12	(0.01–0.24)	0.046
Year of Course	Fifth	Ref	-	-
	Sixth or more	-0.01	(-0.08–0.06)	0.771
Marital Status	Single	Ref	-	-
	With partner	-0.11	(-0.29–0.07)	0.236
Health Status self-reported	Poor	Ref	-	-
	Good / Very good	0.02	(-0.14–0.18)	0.818
Chronic Diseases	No	Ref	-	-
	Yes	-0.02	(-0.17–0.14)	0.850
Familiarity for Chronic diseases	No	Ref	-	-
	Yes	-0.09	(-0.20–0.01)	0.082
Knowledge about Gender Medicine	Poor	Ref	-	-
	Good	0.11	(-0.01–0.21)	0.054
Have you ever dealt with gender medicine issues during lessons? Answer: Yes		0.08	(-0.03–0.19)	0.182
During traineeships in the wards, did you ever discuss with the tutor about the impact of sex and gender on patient management? Answer: Yes		-0.02	(-0.15–0.11)	0.726
During the traineeships in the wards, did you have the impression that the tutor took into consideration sex and gender of patients during clinical practice? Answer: Yes		0.15	(0.03–0.26)	0.014

Discussion

To the best of our knowledge, there are no previous studies in Italy assessing Gender Awareness in medical students. The aim of this study was to evaluate gender awareness and to explore possible predictors of gender sensitivity and gender stereotypes towards patients and doctors in a sample of medical students of the University of Turin. Our students showed higher GS score compared to other European students. Probably, in Italy, there is a greater gender sensitivity because female social conquests are lower than northern Europe. With 63 out of 100 points, Italy ranks 14th in the EU on the Gender Equality Index [23] (12th in the domain of health). This probably increases student’s consideration of gender issues [24]. We found higher Gender sensitivity in female students, probably because female suffer the consequences of gender inequalities. This gender difference is not found in similar studies conducted in Switzerland, Sweden and Netherlands [19,21] and it could be explained considering the specific socio-cultural context of each country. In fact, social status of women is better in many European countries compared to Italy. For example, in Sweden gender equality is highly considered in several social dimensions and in health-care services (Sweden ranks 1st in the EU on the Gender Equality Index) [19,24].

A better knowledge about gender medicine and having a tutor who took in consideration sex and gender of patients during clinical practice were associated with higher GS. Our results suggest that the behaviour of the tutors influences student’s gender sensitivity. We think that the tutors could stimulate interest towards this discipline. Other studies found an increasing GS score with age and lower score in students who had a father with different birth country [19,21]. Regarding gender stereotypes toward patients, we observed mean GRIP score of 1,87 in male and of 1,87. These results are comparable with a Swedish study [19] but they are lower than other results found in Netherlands and Switzerland [19,21]. Moreover we found that GRID score in our sample of Italian students is the lowest among European studies [19,21]. Despite living in a society where gender gap is still high (70th place in the global gender gap report 2019), Italian medical students have less stereotypical thinking regarding the role of gender in medicine compared to their colleagues in Europe [25]. It is important to consider that the European context is in any case much better in terms of gender inequalities in health than in developing countries [26]. Literature shows significant sex-related differences in gender-role ideologies towards patients in European studies, but in our study we observed sex-related difference in gender-role ideologies toward doctors (mean male GRID score is 1,64, mean female GRID score is 1,51; p = 0.028) but not toward patients. Consistently with our study, Portuguese data found less stereotypical thoughts toward doctor in females than males (21). Socio-cultural factors such as the Italian gender gap probably explain the highest scores in gender stereotypes in male students. Multivariable analysis shows an increasing GRIP score with age, better knowledge of gender medicine and having had a tutor that took into consideration gender and sex of patients during clinical practice. Previous studies show that stereotypes decreased with students getting older. Proceedings with their studies, Swedish and Swiss medical students reduce their stereotypes probably for a good theoretical and practical teaching system [19,21]. In Italy, the stereotypes observed were lower than other studies. Nonetheless, we found an increasing GRIP and GRID score with students’ age. This is in contrast with other studies. The teaching of gender medicine and the student’s experience during traineeship increase stereotypes and do not reduce it. Probably, students acquired the stereotypical gender difference as real gender differences. We found that a better knowledge and a good consideration of gender and sex of patients by the tutor were associated with higher gender stereotypes. A possible explanation of these results is a lack of awareness about stereotypes thoughts. A greater knowledge of real gender difference in medicine and greater interest of the tutor on gender and sex during clinical activities could lead to wrong acquisition of common gender beliefs. Nevertheless, our results indicate that GS is higher and stereotypes are lower than other European studies. Italian students are sensitive to gender medicine and have substantially few stereotypes. However, our country does not have a curricular program to prevent gender stereotypes toward both patients and doctors. It is important to teach the students that socio-cultural stereotypical differences are not real differences and are not part of gender medicine. Therefore, the implementation of gender specific teaching throughout elective courses should be seriously considered. Speaking about gender stereotypes in order to improve gender specific medicine is a priority. The teaching of gender medicine should reduce stereotypical thoughts and false beliefs and can contribute to create a real ‘patient-centered medicine’.

Limitations

The principal limitation of this study is that it was conducted on a convenient sample of students attending the last years of medical training; it could be interesting to know if gender awareness is different between freshman students and students of the last years. It is possible that students previously sensitized or interested in the gender dimension of health answered the survey in a larger proportion and were over-represented.

Strengths

We used a validated tool (N-GAMS) to assess gender awareness among medical students. This study is the first, to our knowledge, to have assessed gender awareness among Italian medical students. Other studies can be compared to our study in order to confirm our results in Italian medical student from different cities.

Conclusions

In conclusion, the results of this study indicate that our students have high gender sensitivity and low gender stereotypes towards patients and doctors. However, age, higher knowledge of gender medicine and having had a tutor that took in consideration gender in clinical practice were associated with higher gender stereotypes. During gender courses and practical training more attention must be paid to explain that stereotyped gender differences are not scientifically proven and they do not contribute to provide a better care for both male and female patients. Further studies are needed for a better understanding of the factors that could reduce gender stereotypes in medical students.

1 Sep 2021

PONE-D-21-25375

Are 2020’s medical students still suffering from gender stereotypes? An Italian cross-sectional study

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Reviewer #1: In many diseases, such as coronary artery disease, Parkinson disease, irritable bowel

syndrome, neck pain, knee joint arthrosis and tuberculosis, men are treated more extensively

than women (8).

Research found that physicians are more likely to consider symptoms reported by men as organic (8). Gender awareness in doctors aims to equity and equality in health

Method section

A sample of 1258 students received an email with

the background,

Reviewer #2: 1. The topic is relevant

2. I will suggest that the authors give a proper description of the variables that were used for measurement in the analysis.

3. Tables 1, 3, 4 and 5 in the results section have the same questions. This makes it difficult to ascertain the variables that are being measured and how the results were obtained. If possible, the authors should properly distinguish between the tables to make for easier understanding of the results.

4. I will also suggest that the authors provide a more detailed exploration of gender sensitivity and gender role ideology using, if possible, a theoretical framework.

5. The authors should include a flow chart to show how participants were recruited into the study.

6. The statement "With 63 out of 100 points, Italy ranks 14 in the EU on the Gender Equality Index....." in the Discussion section should be appropriately referenced.

7. The word "Globally" in the results section should be replaced with another word that describes the context of the study population.

Reviewer #3: Title and significance of the manuscript

The title of the manuscript succinctly and adequately describes the scope of the work reported in the article. The work is significant and worth publishing in PLOS ONE given the relevance and importance of the findings on gender stereotyping, be it for the practitioner or patient in medicine particularly as it concerns medical education and practice particularly in Italy and around the world in general.

The manuscript is well written in clear and simple language for the readers to understand.

Materials and methods

The data collection and analysis procedures were adequately presented by the authors. The description of the content of the study tool i.e. the questionnaire is good.

It is suggested that the ethical approval reference number assigned to the study protocol on which data this paper is based be provided in the last sentence of the first paragraph of the materials and methods section of the manuscript.

Results

It would be good if the authors could add the age range of the participants and their socio-demographic characteristics in Table 1.

In the results section, the titles of all the five tables presented in the paper ought to have been typed at the top of the tables contrary to the bottom of the tables as presently presented by the authors. This needs to be corrected.

Recommendation

The manuscript is publishable with minor corrections to be done by the authors.

Reviewer #4: This is an interesting study because gender profoundly influence interactions between health care providers and patients. Overall the manuscript represents valuable information regarding stereotypes in gender medicine including gender sensitivity (GS), role ideology toward patients (GRIP) and role ideology towards doctors (GRID). The study findings could be a good contribution to health science. Although there are important findings in the context of medical students in Italy, the design is repetition of previous work. In general, I recommend this paper to be considered for acceptance after responding several following comments:

1. Research regarding gender-based differential patterns of care by health providers arise predominantly from the developed countries. In my opinion, similar studies from developing countries are also important to be compared. Could you elaborate more on this issue? For example a study below presents the role that gender has on health.

Fikree, F. F., & Pasha, O. (2004). Role of gender in health disparity: the South Asian context. BMJ (Clinical research ed.), 328(7443), 823–826. https://doi.org/10.1136/bmj.328.7443.823

2. Page 5, the questionnaire section: After a review of the literature, a 29-items questionnaire was developed. Please be more detail on how to develop the questionnaire through the literature review.

3. This study used survey instrument- a questionnaire containing the N-GAMS scale to measure gender awareness. Is it in italian-language questionnaire? If yes, how the translation process and validation?

4. Kindly indicate the reasons why students of the fifth and sixth years and outside prescribed time were chosen for this study.

Reviewer #5: In many diseases, such as coronary artery disease, Parkinson disease, irritable bowel

syndrome, neck pain, knee joint arthrosis and tuberculosis, men are treated more extensively

than women (8). Research found that physicians are more likely to consider symptoms reported by men as organic (8).Gender awareness in doctors aims to equity and equality in health.

Did you mean to say these diseases are treated more extensively by men than women?

Kindly explain and paraphrase your sentence properly.

Sentence structure paraphrasing needed

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: DR AJOKE REVIEW.docx

Click here for additional data file.

Submitted filename: DR AJOKE REVIEW PLOS.docx

Click here for additional data file.

14 Oct 2021

Dear Editor,

We are submitting the revised version of our manuscript “Are 2020’s medical students still suffering from gender stereotypes? An Italian cross-sectional study”, according to the comments of the reviewers.

Rev 1:

We would like to thank you for your useful considerations.

Rev 2:

1. I will suggest that the authors give a proper description of the variables that were used for measurement in the analysis.

Thank you for this useful suggestion. We added the following paragraph in the Materials and Methods section:

“This paper focuses on the fourth part of questionnaire, assessing gender sensitivity and gender stereotypes in medical students and their association with socio-demographic features, gender medicine knowledge and training experience regarding gender medicine.

Table 1 displays the variables assessed to describe the sample, stratified by gender. In particular, we explored the following characteristics: age, year of course, nationality, marital status, having children, self-perceived health status, having one or more chronic diseases, familiarity for chronic diseases. Self-perceived health status was assessed with a Likert scale, ranging from 1 (very bad) to 5 (very good), and it was subsequently dichotomized in “not good” (score 1 and 2) and “good/very good” (score 3, 4 and 5). Gender medicine knowledge was assessed with questions regarding the correct definitions of sex, gender and gender medicine, gender-related epidemiology of frequent diseases, and true/false questions regarding specific gender medicine issues.

Personal experience during academic training were assessed asking the students whether they have dealt with gender medicine issues during lessons and during traineeships in the wards”.

2. Tables 1, 3, 4 and 5 in the results section have the same questions. This makes it difficult to ascertain the variables that are being measured and how the results were obtained. If possible, the authors should properly distinguish between the tables to make for easier understanding of the results.

Thank you for this suggestion. However, we think that a modification of the tables is not necessary, as they report the results of different analysis. In particular, table 1 reports the description of the sample, while tables 3, 4 and 5 report the results of the multivariable regression model exploring the potential predictors of Gender Sensitivity (table 3), GRIP (table 4) and GRID (table 5), as specified in the text.

3. I will also suggest that the authors provide a more detailed exploration of gender sensitivity and gender role ideology using, if possible, a theoretical framework.

Thank you for your comment. We modified as follow:

“Gender sensitivity includes the awareness that gender has an impact on health, and affects the presentation of health complaints. This sensitivity allows healthcare professionals to effectively address gender and improve care for both men and women (13). Gender-role ideology represents a health care worker’s attitude towards male and female patients and doctors (14). Furthermore gender-role ideology is present at different levels in health services. Gender role ideology towards patients are a risk factor for inadequate care. For example, several studies show that doctors often attribute psychological symptoms to women for the same symptoms reported (15). Gender role ideology towards doctors instead refer to false beliefs such as thinking that female doctors are more empathic than male doctors (16).”

4. The authors should include a flow chart to show how participants were recruited into the study.

Thank you for this comment. As described in the Materials and Methods section we sent the e-mail with the link to online questionnaire to all the medical students of the fourth, fifth year and outside prescribed times, with no exclusion criteria. A total of 1258 students received the e-mail and 430 of them filled in the questionnaire, thus representing our study population. We think that a flow chart would not add any other relevant information on the recruiting process.

5. The statement "With 63 out of 100 points, Italy ranks 14 in the EU on the Gender Equality Index...." in the Discussion section should be appropriately referenced.

Thank you, we inserted the correct reference.

6. The word "Globally" in the results section should be replaced with another word that describes the context of the study population.

We replaced the word “Globally” with this sentence: “A sample of 430 students completed the questionnaire correctly.”

Rev 3

1. It is suggested that the ethical approval reference number assigned to the study protocol on which data this paper is based be provided in the last sentence of the first paragraph of the materials and methods section of the manuscript.

Thank you for your comment. We cannot provide a study protocol number because we used the Internal Review Board of the Department of Public Health Sciences, University of Turin.

2. It would be good if the authors could add the age range of the participants and their socio-demographic characteristics in Table 1.

Thank you for this remark. We inserted the missing socio-demographic features in Table 1 (Nationality and Children). Since the participants of this survey were all students with similar age (97% of the participants had an age between 22 and 30 years), we think that age should be properly expressed as mean and SD rather than categorizing it as age classes.

3. In the results section, the titles of all the five tables presented in the paper ought to have been typed at the top of the tables contrary to the bottom of the tables as presently presented by the authors. This needs to be corrected.

We appreciated this comment and we corrected the titles of the tables as suggested.

Rev 4:

1. Research regarding gender-based differential patterns of care by health providers arise predominantly from the developed countries. In my opinion, similar studies from developing countries are also important to be compared. Could you elaborate more on this issue? For example a study below presents the role that gender has on health. Fikree, F. F., & Pasha, O. (2004). Role of gender in health disparity: the South Asian context. BMJ (Clinical research ed.), 328(7443), 823 826. https://doi.org/10.1136/bmj.328.7443.823

Thanks for your comment, we added this part in the discussion section: “It is important to consider that the European context is in any case much better in terms of gender inequalities in health than in developing countries (24).”

We think that it is difficult to compare our results with studies from developing countries. There are no data in the literature on gender awareness in medical students in developing countries.

2. Page 5, the questionnaire section: After a review of the literature, a 29-items questionnaire was developed. Please be more detail on how to develop the questionnaire through the literature review.

Thank you for this comment. As also requested by Reviewer n°2, we added the following paragraph describing the variables analyzed and the construction of the questionnaire.

Table 1 displays the variables assessed to describe the sample, stratified by gender. In particular, we explored the following characteristics: age, year of course, nationality, marital status, having children, self-perceived health status, having one or more chronic diseases, familiarity for chronic diseases. Self-perceived health status was assessed with a Likert scale, ranging from 1 (very bad) to 5 (very good), and it was subsequently dichotomized in “not good” (score 1 and 2) and “good/very good” (score 3, 4 and 5). Gender medicine knowledge was assessed with questions regarding the correct definitions of sex, gender and gender medicine, gender-related epidemiology of frequent diseases, and true/false questions regarding specific gender medicine issues.

Personal experience during academic training were assessed asking the students whether they have dealt with gender medicine issues during lessons and during traineeships in the wards”.

As specified in the text, the only part of the questionnaire derived from the literature was the N-GAMS scale, for which we provided the appropriate citation.

3. This study used survey instrument- a questionnaire containing the N-GAMS scale to measure gender awareness. Is it in italian-language questionnaire? If yes, how the translation process and validation?

We appreciate this comment. We add this sentence: “The questionnaire was in Italian-language. A bilingual researcher translate the tool from English to Italian. The translated N-GAMS scale was then tested for understandability in a pilot study recruiting 20 medical students.”

4. Kindly indicate the reasons why students of the fifth and sixth years and outside prescribed time were chosen for this study.

We appreciate this comment. We completed the text in the Material and Methods section as follows: “The questionnaire was submitted to students of the last years of the degree course because they already had practical training experiences with patients and had received an important part of theoretical training”.

Rev 5:

1. In many diseases, such as coronary artery disease, Parkinson disease, irritable bowel

syndrome, neck pain, knee joint arthrosis and tuberculosis, men are treated more extensively than women (8). Research found that physicians are more likely to consider symptoms reported by men as organic (8). Gender awareness in doctors aims to equity and equality in health. Did you mean to say these diseases are treated more extensively by men than women? Kindly explain and paraphrase your sentence properly.

Thank you for your consideration. We added information about this as follows:

In many diseases, such as coronary artery disease, Parkinson disease, irritable bowel syndrome, neck pain, knee joint arthrosis and tuberculosis, men are treated more extensively than women (8). Research found that physicians are more likely to consider symptoms reported by men as organic (8). These differences, if not properly considered, can lead to health inequality. In particular, some pathologies can be undertreated in women compared to men or vice versa. For this reason, it is important that doctors are aware of gender differences during their clinical practice.

Submitted filename: Response to Reviewers .docx

Click here for additional data file.

3 Nov 2021

PONE-D-21-25375R1Are 2020’s medical students still suffering from gender stereotypes? An Italian cross-sectional studyPLOS ONE

Dear Dr. Boietti,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Ramune Jacobsen

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1 Title issue Very good article but my concern is that a research question cannot be a title.

Kindly consider and change the title into a statement and not a question, the question can be included as part of your introduction, along with your aim of study

4 Data absent Kindly include the data to reveal instances about gender differences influencing health.

Please state clearly the impact (state wise, nationally and globally) and effect on people’s health, physically, socially, mentally e.t.c

Which is one of the reasons why you must have chosen the topic.

Study Rationale Invariably including a strong rationale for this study would have brought out the best of this article

Reviewer #2: The authors have taken time to address all the comments that were raised by reviewers in the initial submission.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: Please check the attached.

Tile, rationale and methods.

Pages

Queries

My suggestions to the author

1

Title issue

Very good article but my concern is that a research question cannot be a title.

Kindly consider and change the title into a statement and not a question, the question can be included as part of your introduction, along with your aim of study

4

Data absent

Kindly include the data to reveal instances about gender differences influencing health.

Please state clearly the impact (state wise, nationally and globally) and effect on people’s health, physically, socially, mentally e.t.c

Which is one of the reasons why you must have chosen the topic.

Study Rationale

Invariably including a strong rationale for this study would have brought out the best of this article

Thank you

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Olaoluwa Pheabian Akinwale

Reviewer #4: No

Reviewer #5: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: DR AJOKE REVIEW PLOS.docx

Click here for additional data file.

Submitted filename: Gender Sterotype Dr Ajoke.docx

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1 Dec 2021

Dear Editor,

We are submitting the revised version of our manuscript “Are 2020’s medical students still suffering from gender stereotypes? An Italian cross-sectional study”, according to the comments of the reviewers.

Rev 1:

1 Title issue Very good article but my concern is that a research question cannot be a title.

Kindly consider and change the title into a statement and not a question, the question can be included as part of your introduction, along with your aim of study

4 Data absent Kindly include the data to reveal instances about gender differences influencing health.

Please state clearly the impact (state wise, nationally and globally) and effect on people’s health, physically, socially, mentally e.t.c

Which is one of the reasons why you must have chosen the topic.

Study Rationale Invariably including a strong rationale for this study would have brought out the best of this article

We would like to thank you for your useful considerations.

We modified title: “Gender sensitivity and stereotypes in medical university students: An Italian cross-sectional study”.

We have also modified the introduction as follows:

“A Danish study with a sample of 6.9 million patients, reports that women receive a diagnosis of disease 4 years later than men(8). Another study reports that the in-hospital mortality of an acute myocardial infarction (AMI) is higher in women than in men up to 70 years of age and survival after 6 months of AMI is lower in women(9).”

“The focus on a medicine that takes gender differences into account begins in the 80s with the signing by the UN (United Nation) of a convention aimed at eliminating all forms of discrimination against women(22). In Europe, a growing interest in gender medicine led to the inclusion of this issue in the new Horizon 2020 research funding program(22). In Italy, a Plan for the application and diffusion of Gender Specific Medicine (2019) aims to spread the principles of gender specific medicine that are not yet fully and adequately implemented in medical academic training (22). For this reason, the aim of this study is to evaluate gender awareness through N-GAMS scale and its predictors in Italian male and female medical students, since no data exist in literature about gender awareness in our national context.”

Finally, we want to thank the other reviewers for their helpful consideration.

Submitted filename: Response to Reviewers .docx

Click here for additional data file.

23 Dec 2021

Gender sensitivity and stereotypes in medical university students: An Italian cross-sectional study

PONE-D-21-25375R2

Dear Dr. Boietti,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ramune Jacobsen

Academic Editor

PLOS ONE

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: All the comments and questions raised in previous versions of the manuscript have been addressed by the authors.

Reviewer #3: The manuscript was presented in an intelligible fashion and written in standard English, and the authors have addressed satisfactorily all my concerns in their responses.

Reviewer #4: (No Response)

Reviewer #5: All the best in the future

Pages Queries My suggestions to the author

1 Title issue Very good article but my concern is that a research question cannot be a title.

Kindly consider and change the title into a statement and not a question, the question can be included as part of your introduction, along with your aim of study

4 Data absent Kindly include the data to reveal instances about gender differences influencing health.

Please state clearly the impact (state wise, nationally and globally) and effect on people’s health, physically, socially, mentally e.t.c

Which is one of the reasons why you must have chosen the topic.

Study Rationale Invariably including a strong rationale for this study would have brought out the best of this article

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: Yes: Prof Olaoluwa Pheabian Akinwale

Reviewer #4: No

Reviewer #5: No

28 Dec 2021

PONE-D-21-25375R2

Gender sensitivity and stereotypes in medical university students: An Italian cross-sectional study

Dear Dr. Boietti:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ramune Jacobsen

Academic Editor

PLOS ONE