Gender diversity in academic medicine
A promising diversity incentive comes to a premature end in the UK
Sarah Stewart-Brown professor of public health

The BMJ analysis article examining the effect of gender diversity incentives in the UK’s National Institute of Health Research (NIHR) funding awards process (doi:10.1136/bmj.m3975)1 has come at an
interesting time.
Athena SWAN is a three level charter (bronze, silver, and gold) offered since 2005 to organisations that meet criteria to increase gender diversity. In 2011, the then chief medical officer and head of NIHR, Sally Davies, introduced a requirement that applicants for NIHR grants and places on academic training schemes must be working in institutions that held at least a silver Athena SWAN award. In September, as part of new measures to reduce bureaucracy for UK researchers in the wake of the covid 19 pandemic, Louise Wood, co-lead for NIHR, announced an end
to this requirement.2 Wood’s announcement will come as a blow to those who believe gender equality
to be a basic human right and gender diversity to be vital to the quality of health and medical research.
When the Athena SWAN charter was first introduced, many saw it as a box ticking exercise that might tackle the superficial issues in gender diversity but
not the deeply ingrained ones. Sally Davies’ initiative, however, seemed to stimulate awareness and activity
around gender diversity in medical schools, leading to a 10-fold increase in silver and gold awards.
Ovseiko and colleagues’ analysis1 shows little change from 2006 to 2011 followed by an important
improvement in gender balance among leaders of NIHR research themes; by 2016 the proportion of women in that role had risen threefold (to 24%) and the proportion of funding they acquired had increased more than fourfold.
Disappointingly, there was no change in the extreme gender imbalance among the more senior NIHR centre directors, but the change in theme leads is important because these individuals can progress to become directors. The analysis was observational, so cannot prove causality, but if 2021 data, when available,
show a continued improvement, the evidence supporting an “Athena SWAN” effect would be highly suggestive.
Long way to go
In defence of her decision, Wood suggests that Athena SWAN has done its work and that gender diversity is now valued and supported throughout academic medicine, so the substantial administrative burden is no longer necessary.2 Her optimism seems misplaced. We have yet to reach critical mass in terms of female theme leads, and the more powerful and influential centre directors remain overwhelmingly male.

That gender diversity matters for health and for research is still not widely accepted by male academic leadership, and the reasons underpinning endemic gender imbalance are not fully understood.
Ovseiko and colleagues cite evidence that gender diversity is important because it delivers research that is more interdisciplinary, higher quality, more rigorous, and more relevant.1 Studies have shown that women leaders get higher scores than men in multisource feedback exercises used in the UK to support the appraisal process.3 They outperform men not just in traditional female traits such as nurturing, but also in qualities such as taking initiative, driving for results, and displaying integrity and honesty.
To this can be added that medical women are over represented in general practice and in the lower profile disciplines such as mental health, care of older people, and child health, where both the burden of disease and the cost to the public purse are high but the research base is relatively weak. Rebalancing gender inequity in academic medicine should lead to a more even distribution of evidence for practice.
Reasons for the gender imbalance in academic medicine include an unequal distribution of caring responsibilities and associated part time working or career breaks. But these factors do not fully account for gender discrepancies,4 and universities are increasingly sympathetic to career breaks and part time working (for both women and men) in academic promotion. Unconscious bias is another contributor. This is being partially addressed through research identifying these biases,5 and by the implementation of anonymous peer review processes.
Also likely to be relevant are gender differences in response to competition.6 7 Competition is stressful. The stress response in humans is complex and likely to be gender related.8 Studies suggest that men are more likely to exhibit a fight or flight response and women a freeze or fold response.7 8 Neither are optimal in terms of creativity, productivity, and problem solving, but the fight response is less disabling in a competitive world. Competition is still believed to be motivating and helpful despite long standing research suggesting the opposite.7 This enduring belief is likely to be serving male advantage in the academic world at the expense of high quality research.
Athena SWAN has been helpful in encouraging medical schools to reduce structural gender imbalances and think about unconscious bias, but it does not resolve issues related to the highly competitive culture of academic medicine. Gender imbalance will remain and research quality will suffer


until we move towards an academic system in which collaboration is valued over competition.

Competing interests: I have read and understood BMJ policy on declaration of interests and have no interests to declare.

Provenance and peer review: Commissioned; not externally peer reviewed.

1 Ovseiko P, Taylor M, Gilligan R, etal. Athena SWAN-linked funding incentives accelerate women’s research leadership. BMJ 2020;371:m3975. doi: 10.1136/bmj.m3975
2 NIHR responds to the government’s call for further reduction in bureaucracy with new measures. 2020. https://www.nihr.ac.uk/news/nihr-responds-to-the-governments-call-for-further-reduction- in-bureaucracy-with-new-measures/25633
3 Sherwin B. Why women are more effective leaders than men. Business Insider 2014 Jan 24.https://www.businessinsider.com/study-women-are-better-leaders-2014-1?r=US&IR=T
4 Komlenac N, Gustafsson Sendén M, Verdonk P, Hochleitner M, Siller H. Parenthood does not explain the gender difference in clinical position in academic medicine among Swedish, Dutch and Austrian physicians. Adv Health Sci Educ Theory Pract 2019;24:539-57.
doi: 10.1007/s10459-019-09882-9 pmid: 30840215
5 Witteman HO, Hendricks M, Straus S, Tannenbaum C. Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency. Lancet 2019;393:531-40. doi: 10.1016/S0140-6736(18)32611-4 pmid: 30739688
6 Price J. Gender differences in the response to competition. ILR Review 2008;61:320-33. doi: 10.1177/001979390806100303
7 Kohn A. No Contest; The case against competition. Houghton Mifflin, 1986.
8 Baldwin DV. Primitive mechanisms of trauma response: an evolutionary perspective on trauma-related disorders. Neurosci Biobehav Rev 2013;37:1549-66.
doi: 10.1016/j.neubiorev.2013.06.004 pmid: 23792048 M4076