Disproportionate gender representation in orthopaedics and its research

The burning topic of gender inequalities and diversities in Research and Publications has recently come into the foray and is discussed widely. It is often argued that in most disciplines of medicine, women are under-represented, publish fewer articles, and receive fewer citations than males. There are two contrasting opinions on the reasons for gender inequality and imbalance. Some attribute it to the ambitions and attitude of women, whereas others claim it to be due to a systemic and cultural bias against women.¹ Volerman et al.² reported that disparities in gender representation exist among the researchers throughout the career, including receiving grants and awards. Some social advocates have further suggested that gender and diversity issues are responsible for social injustice and the societal relevance of the research rather than research integrity. Whereas the opposing groups feel that addressing the issues of quality, relevance, and reliability of the research are far more important than the issues related to social justice and societal relevance.³ It is also crucial that scientific objectivity and trust in the science are maintained, irrespective of ‘who’ is publishing it. If the research and publications become biased related to gender or other types of diversity, its trust worthiness is undermined.

1. The problem

Generally, most surgical specialties under-represent females, whereas this inequality is lesser or nonexistent in the medical specialities and paramedical branches. The least female representation in the surgical specialties includes otolaryngology, plastic surgery, urology, neurosurgery, and orthopaedic surgery. It is estimated that this gender parity will take decades to reach a comparable female representation level. In Orthopaedics, it may even take more than a century to achieve this goal.⁴ Although females account for approximately half of the medical students, their representation in the Orthopaedic post-graduate training is mainly scarce, around 14%, in the US and much lesser in other parts of the world.⁵ In the developed world they account for about 5%, whereas in India they are only about 1%.⁶

2. Probable reasons

Several reasons have been identified for the reservation amongst females to join Orthopaedic as a career choice. These factors may include discrimination in promotion, gender bias, work-life balance, inability to achieve full working potential, and lack of suitable mentorship.⁶Other dissuading factors include personal reasons, like their perception that ‘too much strength is required,’ dislike for manual work, and operating theatres.⁵

3. Suggested remedies

Several actions are to be taken to bridge the enormous gap in gender inequality. Some of these could be the presence of a role model for the womenin higher ranks, counseling for achieving work-life balance, avoiding discrimination and helping them reach their full potential, no-tolerance policies to deal with any sexual harassment, and non-intimidator teaching methods. In addition, some more positive influences may allow them to opt for the orthopaedic specialty. These could be adequate exposure to musculoskeletal (MSK) conditions and strong mentors in their medical school, the presence of an Orthopaedic surgeon in the family, their interest in sports, and if they or their family member had an orthopaedic surgery.⁵

4. Gender inequalities in research and publication

It is debatable if there is a strong gender bias exists in the field of research and publication. Based on 20 years of data from Scopus, Elsevier has found that the overall representation of women in research is increasing, but inequality remains. More efforts are needed to ensure equality for women in terms of publication outputs, citations, awarded grants, and collaborations.¹ Huang et al.⁷ conducted a bibliometric analysis of publications of 1.5 million gender-identified authors (between 1955 and 2010). They paradoxically found increased participation of women in research and publications in the last 60 years. Also, men and women published at a comparable rate and had a similar impact career-wise for the same work.

Further, the men represent more as the authors with a long publication history than the women.¹ Thomas et al.⁸ noticed that women had lower odds of writing invited articles than men with similar professional experience and standing, offering the men an advantage over them and lead to gender inequity. It is suggested that there needs to be a focus on developing fair, data-driven approaches to find experts for the invited articles in the future to avoid such bias. Most surgical branches, especially Orthopaedics, currently have a sparse representation of women. Therefore, to label gender inequalities in research and publication in such specialties is unfair and not justified now.

5. Perceived advantages of increased female representation

The debate of gender diversity and achieving equalities in research and publication is healthy and should bridge the gaps. The increased representation of women in Orthopaedics would bring positivity in the work-culture by increased sincerity, improved patient-doctor relationship, increased focus and research on the women and children health-related MSK problems, and good governance. It is essential to note that as women entered into the field of research and publications in the 1980s and 1990s, in the US, there was greater attention and impact on the women's health-related issues like breast cancer, osteoporosis, auto-immune, and heart diseases.^9,10

It is a fact that the volume of research and the growth of publications in Orthopaedics is continually rising every year, including in India.¹¹ It is becoming a necessity, rather than an obligation for all the professionals to advance their careers. It is essential that the research is done on the local problems and provides solutions to society for their health benefits. However, it is essential to realize that stopping publishing does not necessarily imply an end of the academic career. On the contrary, the authors who stopped publishing may retain administrative, teaching, or posts with less pressure. Moreover, the scientific publications may represent one possible scholarly output, but books and patents are equally important.⁷

Although, it is challenging to find adequate number of women in the field of Orthopaedics, to fulfill the desired goal of bridging the gender inequality in the editorial board, we at the Journal of Clinical Orthopaedics and Trauma have taken the issue seriously and have expanded the board to diversify it by including more female editors, and they now represent at 9% of the total number of editors. We feel that it is a remarkable and positive achievement, considering their low numbers (around 1% in India), in the Orthopaedic speciality.

Two quotes from famous personalities can encapsulate the issue of gender inequality and diversity: “Gender equality is more than a goal in itself. It is a precondition for meeting the challenge of reducing poverty, promoting sustainable development, and building good governance”- Kofi Annan, the former Secretary-General of United Nations, and “Our ability to reach unity in diversity will be the beauty and the test of our civilization.“- Mahatma Gandhi, the ‘father of nation’ of India.