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British Journal of Anaesthesia
BJA

Women in anaesthesia, a special issue of the British Journal of Anaesthesia

Open ArchivePublished:January 20, 2020DOI:https://doi.org/10.1016/j.bja.2019.12.038

      Keywords

      Women in anaesthesia—they have always been there, as patients (Sir James Young Simpson's use of chloroform for childbirth in the mid-19th century) and anaesthetists (anaesthesia in the late 19th century in the USA was often done by female nurses),
      • Calmes S.
      The history of women an American anesthesiology.
      and more recently, as clinical anaesthesiologists, researchers, and educators. However, as noted in this special issue of the British Journal of Anaesthesia (BJA), female patients remain under-represented in research cohorts, and as in other medical specialities, women lag behind in leadership positions in anaesthesiology and are under-represented in the specialty compared with the proportion of women in medicine.
      Women comprise at least 50% of medical school students in most Western countries, yet it is well recognised that the lack of sex and gender diversity in medical leadership and research positions is detrimental to the profession and women's health. The first step to correct a problem is to recognise, describe, and measure it. The Lancet devoted its February 9, 2019 issue to advancing women in science, medicine, and global health.
      • The Lancet
      Advancing women in science, medicine, and global health.
      Major anaesthesiology journals are increasingly publishing articles addressing the status of women in anaesthesia, and recent major anaesthesiology meetings have included panels addressing gender equity and inclusion.
      This special issue of the BJA is timely in this regard, and collects clinical and laboratory investigations, reviews, special articles, and correspondence focused on Women in Anaesthesia. The issue publication date is March 8, 2020 to coincide with International Women's Day (https://www.internationalwomensday.com). The effort was launched 9 months ago with the Women in Anaesthesia Research Symposium held in Prato, Italy, and sponsored by the BJA and Monash University, Australia.
      • Boer C.
      • Moonesinghe S.
      Women empowerment in anaesthesia research and clinical practice. Summary from the British Journal of Anaesthesia ‘Women in Anaesthesia Research’ symposium.
      The articles address several major themes, including the current status of women anaesthesiologists, the status of women in anaesthesiology research and education, women as subjects in anaesthesiology research cohorts, clinical investigations that focus on women patients, and laboratory studies that address the issue of sex as a biologic variable.
      Semantics are important here. While writing and editing the articles for this issue, the authors and editors struggled with the semantics, as have authors of many previous studies published in anaesthesiology journals.
      • Leslie K.
      • Edgley C.
      • Lee A.C.
      • Sellar A.
      • Sgroi J.
      • Toh R.
      Reporting of sex and gender in human studies published in anaesthesia journals.
      The words gender and sex are not synonymous. As noted by Leslie and colleagues,
      • Leslie K.
      • Edgley C.
      • Lee A.C.
      • Sellar A.
      • Sgroi J.
      • Toh R.
      Reporting of sex and gender in human studies published in anaesthesia journals.
      ‘Sex is a biological state defined by chromosomes, gonads, genitals, and secondary sexual characteristics. “Gender” is a set of attitudes, feelings, and behaviours linked to a person's identity as a man, woman, both, neither, or of fluid identity’.
      An additional source of confusion is that the words ‘female/male’ and ‘women/men’ are nouns, but only ‘female’ and ‘male’ are adjectives. Grammar purists object to the phrase ‘women anaesthesiologists’ rather than ‘female anaesthesiologists’. But others may object to attaching a biological label to their profession. It has been suggested that ‘women anaesthesiologists’ can be used as a (grammatically correct) apposite noun (a noun or noun phrase that renames a noun right next to it
      • Simmon R.
      The appositive.
      ).
      • Waldman K.
      We acknowledge that using the terms ‘women’ and ‘men’ implies that gender identity is binary, although these labels do not adequately portray the spectrum of gender experience.
      Sex and gender are key determinants of health and must be considered in the design, analysis, and reporting of perioperative medicine research. In an authoritative editorial, Leslie and Kasza
      • Leslie K.
      • Kasza J.
      Sex and gender inclusion, analysis and reporting in anaesthesia research.
      summarise current legislative, regulatory, policy, and guideline initiatives that promote gender and sex inclusiveness in medical research, and suggest processes for improvement. They suggest that ‘better evidence about the effects of sex and gender on health is critical to improving health care for everyone’ and that ‘international consensus and enforcement of inclusion of women and sex/gender analysis and reporting is required’.
      Several articles in this issue address the position of women in anaesthesiology. A scoping review by Bosco and colleagues
      • Bosco L.
      • Hastie M.
      • Flexman A.
      • Lorello G.
      Women in anaesthesia: a scoping review.
      provides an overview that explores gender issues in anaesthesiology and identifies gaps in the literature and effective strategies to improve gender equity in anaesthesiology. The authors concluded that women are under-represented in academic positions, in journal authorship, as editorial board members, and as award recipients, and that in some countries women are remunerated at a lesser rate than their male colleagues.
      • Bosco L.
      • Hastie M.
      • Flexman A.
      • Lorello G.
      Women in anaesthesia: a scoping review.
      Many of these concerns are also articulated in other articles in this issue.
      • Boer C.
      • Moonesinghe S.
      Women empowerment in anaesthesia research and clinical practice. Summary from the British Journal of Anaesthesia ‘Women in Anaesthesia Research’ symposium.
      ,
      • Lane-Fall M.
      • Gordon E.
      • Valentine E.
      • Black S.
      • Kapur P.
      • Fleisher L.
      Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists.
      • Bustillo M.
      • Gotian R.
      A mentoring circle supports women anaesthesiologists at every career stage.
      • Patel R.
      • Moonesinghe S.
      A seat at the table is no longer enough: practical implementable changes to address gender imbalance in the anaesthesia workplace.
      • Gonzalez L.
      • Fahy B.
      • Lien C.
      Gender distribution in United States anaesthesiology residency programme directors: trends and implications.
      • Minehart R.
      • Foldy E.
      • Long J.
      • Weller J.
      Challenging gender stereotypes and advancing inclusive leadership in the operating theatre.
      • Samuel K.
      • Ellicott H.
      Gender inequality in research – does UK trainee led research herald an equal future?.
      • Boerman L.
      • Bullens A.
      • van der Wal R.
      Gender disparity in academic performance in anaesthesiology in the Benelux.
      • Zdravkovic M.
      • Osinova D.
      • Brull S.
      • Prielipp R.
      • Simões C.
      • Berger-Estilita J.
      Anaesthesiologists’ perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11,746 anaesthesiologists.
      • Matot I.
      • de Hert S.
      • Cohen B.
      • Koch T.
      Women’s attitudes and reported barriers to career advancement in anaesthesia: a survey of the European Society of Anaesthesiology.
      The results of two large Internet surveys investigating career opportunities in leadership and research among women anaesthesiologists are reported in this issue.
      • Zdravkovic M.
      • Osinova D.
      • Brull S.
      • Prielipp R.
      • Simões C.
      • Berger-Estilita J.
      Anaesthesiologists’ perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11,746 anaesthesiologists.
      ,
      • Matot I.
      • de Hert S.
      • Cohen B.
      • Koch T.
      Women’s attitudes and reported barriers to career advancement in anaesthesia: a survey of the European Society of Anaesthesiology.
      Using an online survey translated into seven languages, investigators collected 11 746 responses from 148 countries over a 6-week period.
      • Zdravkovic M.
      • Osinova D.
      • Brull S.
      • Prielipp R.
      • Simões C.
      • Berger-Estilita J.
      Anaesthesiologists’ perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11,746 anaesthesiologists.
      Women were more likely to perceive mistreatment in the workplace and many more women than men perceived that women were disadvantaged in research and leadership positions. Interestingly, countries with lower average incomes had a smaller gender gap. In a survey of members of the European Society of Anaesthesiology, women respondents were just as likely as men respondents to desire a leadership career, although women perceived more barriers to doing so than men.
      • Matot I.
      • de Hert S.
      • Cohen B.
      • Koch T.
      Women’s attitudes and reported barriers to career advancement in anaesthesia: a survey of the European Society of Anaesthesiology.
      Qualitative analysis of free-text comments allowed detailed identification of perceived problems and suggested solutions.
      • Zdravkovic M.
      • Osinova D.
      • Brull S.
      • Prielipp R.
      • Simões C.
      • Berger-Estilita J.
      Anaesthesiologists’ perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11,746 anaesthesiologists.
      ,
      • Matot I.
      • de Hert S.
      • Cohen B.
      • Koch T.
      Women’s attitudes and reported barriers to career advancement in anaesthesia: a survey of the European Society of Anaesthesiology.
      Tracking progress requires baseline performance to be measured. Work published in this special issue provides a baseline for future evaluations of interventions aimed at improving the gap in gender equity in anaesthesia.
      • Gonzalez L.
      • Fahy B.
      • Lien C.
      Gender distribution in United States anaesthesiology residency programme directors: trends and implications.
      ,
      • Boerman L.
      • Bullens A.
      • van der Wal R.
      Gender disparity in academic performance in anaesthesiology in the Benelux.
      Potential solutions to the recognised gap in gender equity in anaesthesiology are also proposed.
      • Boer C.
      • Moonesinghe S.
      Women empowerment in anaesthesia research and clinical practice. Summary from the British Journal of Anaesthesia ‘Women in Anaesthesia Research’ symposium.
      ,
      • Bosco L.
      • Hastie M.
      • Flexman A.
      • Lorello G.
      Women in anaesthesia: a scoping review.
      • Lane-Fall M.
      • Gordon E.
      • Valentine E.
      • Black S.
      • Kapur P.
      • Fleisher L.
      Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists.
      • Bustillo M.
      • Gotian R.
      A mentoring circle supports women anaesthesiologists at every career stage.
      • Patel R.
      • Moonesinghe S.
      A seat at the table is no longer enough: practical implementable changes to address gender imbalance in the anaesthesia workplace.
      • Gonzalez L.
      • Fahy B.
      • Lien C.
      Gender distribution in United States anaesthesiology residency programme directors: trends and implications.
      • Minehart R.
      • Foldy E.
      • Long J.
      • Weller J.
      Challenging gender stereotypes and advancing inclusive leadership in the operating theatre.
      • Samuel K.
      • Ellicott H.
      Gender inequality in research – does UK trainee led research herald an equal future?.
      ,
      • Boer C.
      • Daelmans H.
      Team up with the hidden curriculum in medical teaching.
      • Pearce G.
      • Sidhu N.
      • Cavadino A.
      • Shrivathsa A.
      • Seglenieks R.
      Gender effects in Australian and New Zealand anaesthesia training.
      • Demailly Z.
      • Brulard G.
      • Selim J.
      • Compère V.
      • Besnier E.
      • Clavier T.
      Gender differences in professional social media use among anaesthesia researchers.
      Several groups have published ‘checklists’ of positive actions that can help close the gender gap. Such a checklist was proposed by Leslie and colleagues
      • Leslie K.
      • Hopf H.W.
      • Houston P.
      • O'Sullivan E.
      Women, minorities, and leadership in anesthesiology: take the pledge.
      in 2017 (they suggested ‘taking the pledge’ to routinely perform 10 items that will facilitate closing the gender gap). Similarly, in a recent editorial, Geagea and Mehta
      • Geagea A.
      • Mehta S.
      Advancing women in academic medicine: ten strategies to use every day.
      listed 10 everyday strategies to advance women in academic medicine. These checklists include being aware of ones implicit biases, speaking up about inequities, formulating policies that address inequities, collecting and reporting data, and addressing gender pay gaps.
      • Leslie K.
      • Hopf H.W.
      • Houston P.
      • O'Sullivan E.
      Women, minorities, and leadership in anesthesiology: take the pledge.
      ,
      • Geagea A.
      • Mehta S.
      Advancing women in academic medicine: ten strategies to use every day.
      In this issue of the BJA, Patel and Moonesinghe
      • Patel R.
      • Moonesinghe S.
      A seat at the table is no longer enough: practical implementable changes to address gender imbalance in the anaesthesia workplace.
      suggest that ‘a seat at the table is no longer enough’, and recommend six ‘amplifications’ to help close the gender gap: amplification of opportunity, voices, inclusion, participation, recognition, and leadership.
      Role models are important. Women medical students and trainees need to know that their predecessors have persevered and succeeded, and that senior women clinicians, educators, and researchers with whom they work have also done so. This issue includes accounts of the inspiring careers of early anaesthesia luminaries: Katharine Georgina Lloyd-Williams (1896–1973),
      Wilkinson D. Katharine Georgina Lloyd-Williams, CBE
      (1896–1973): an inspirational anaesthesia role-model.
      Sarah Joyce O'Malley (1896–1959),
      • O’Brien K.
      • O’Brien B.
      Sarah Joyce O’malley, Irish anaesthetist (1896–1959).
      and Virginia Apgar (1909–74).
      • Oliveira C.
      The legacy of Virginia Apgar.
      They are inspirational role models for everyone, but are of particular significance in this context as they succeeded as professional women in an environment that was overwhelmingly male dominated. The vital importance of positive role models is emphasised in many of the articles in this issue.
      • Boer C.
      • Moonesinghe S.
      Women empowerment in anaesthesia research and clinical practice. Summary from the British Journal of Anaesthesia ‘Women in Anaesthesia Research’ symposium.
      ,9−12,
      • Zdravkovic M.
      • Osinova D.
      • Brull S.
      • Prielipp R.
      • Simões C.
      • Berger-Estilita J.
      Anaesthesiologists’ perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11,746 anaesthesiologists.
      • Matot I.
      • de Hert S.
      • Cohen B.
      • Koch T.
      Women’s attitudes and reported barriers to career advancement in anaesthesia: a survey of the European Society of Anaesthesiology.
      • Boer C.
      • Daelmans H.
      Team up with the hidden curriculum in medical teaching.
      Many academic departments have developed formal programmes to support gender diversity. Lane-Fall and colleagues
      • Lane-Fall M.
      • Gordon E.
      • Valentine E.
      • Black S.
      • Kapur P.
      • Fleisher L.
      Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists.
      describe how Maslow's hierarchy fits into the professional development of individuals, and how this hierarchy can be used to structure a programme of faculty development that focuses particularly on women. They emphasise that a feeling of love and belonging (which follows the necessities of physiological needs and safety at the bottom of the hierarchy) must be achieved before the top levels of the hierarchy (self-esteem and finally, self-actualisation) can be attained. Bustillo and Gotian
      • Bustillo M.
      • Gotian R.
      A mentoring circle supports women anaesthesiologists at every career stage.
      describe how introduction of a women's circle can support faculty development.
      Anaesthesiologists primarily work in a team environment, and teams require a leader who is endowed with the authority to lead. Minehart and colleagues
      • Minehart R.
      • Foldy E.
      • Long J.
      • Weller J.
      Challenging gender stereotypes and advancing inclusive leadership in the operating theatre.
      argue that inclusive rather than authoritative leadership is better suited to the operating theatre, and that women's leadership styles are inherently more inclusive. Current gender leadership stereotypes may interfere with optimal team functioning and bear re-examination in today's complex operating theatre environment.
      • Minehart R.
      • Foldy E.
      • Long J.
      • Weller J.
      Challenging gender stereotypes and advancing inclusive leadership in the operating theatre.
      Training the next generation of anaesthesiologists is a primary mission of academic anaesthesiologists. In the USA, the residency programme director is considered an important academic department leader. Although women are still significantly under-represented in traditional academic leadership roles in the USA and elsewhere,
      • Bissing M.A.
      • Lange E.M.S.
      • Davila W.F.
      • et al.
      Status of women in academic anesthesiology: a 10-year update.
      Gonzalez and colleagues
      • Gonzalez L.
      • Fahy B.
      • Lien C.
      Gender distribution in United States anaesthesiology residency programme directors: trends and implications.
      report that the proportion of women residency programme directors now mirrors that of women anaesthesiologists.
      Pearce and colleagues
      • Pearce G.
      • Sidhu N.
      • Cavadino A.
      • Shrivathsa A.
      • Seglenieks R.
      Gender effects in Australian and New Zealand anaesthesia training.
      examined Australian and New Zealand trainees' perceptions of their numbers and readiness to perform 12 anaesthesiology procedures without senior supervision. More male than female trainees reported that they had performed these procedures at least 10 times. Men were also more confident in their procedural skills and were more likely to exaggerate their procedural experience when queried by supervisors.
      Boer and Daelmans
      • Boer C.
      • Daelmans H.
      Team up with the hidden curriculum in medical teaching.
      highlight the role of the hidden curriculum (implicit messages about values, norms, and attitudes that are ‘taught’ in medical schools without overt thought or formal inclusion in the curriculum) and the role that this hidden curriculum plays in the development of many important traits of the practising physician. These traits are critical to professional aspects of our jobs, and failure to address these issues may contribute to burnout and other stressors often faced by female students and young physicians, widening the gender gap.
      A significant impetus for this special issue was consideration of women in anaesthesiology research.
      • Boer C.
      • Moonesinghe S.
      Women empowerment in anaesthesia research and clinical practice. Summary from the British Journal of Anaesthesia ‘Women in Anaesthesia Research’ symposium.
      Samuel and Ellicott
      • Samuel K.
      • Ellicott H.
      Gender inequality in research – does UK trainee led research herald an equal future?.
      describe gender equity in the UK Research and Audit Federation of Trainees. They propose that this successful group serve as a model for future gender equity among UK anaesthesiology researchers.
      Social networks have taken an increasingly greater role in scientific communication and promotion of individual researchers. Demailly and colleagues
      • Demailly Z.
      • Brulard G.
      • Selim J.
      • Compère V.
      • Besnier E.
      • Clavier T.
      Gender differences in professional social media use among anaesthesia researchers.
      assessed the visibility of women compared with men anaesthesiology researchers on social networks. Despite a similar rate of use of these networks by women, the visibility of women remains lower than that of men, particularly on a social network dedicated specifically to scientific research (ResearchGate). Identifying the causes of these differences and actively managing them provide the potential means to raise the visibility of women scientists.
      High-quality reproductive care is critical to women's health. Irish investigators surveyed conscientious objector status regarding termination of pregnancy following the 2018 referendum vote allowing this procedure in the Republic of Ireland for the first time.
      • MacDonncha C.
      • Brohan J.
      • O’Brien B.
      Conscientious objection to provision of anaesthesia for termination of pregnancy among anaesthesiologists in the Republic of Ireland. A potential obstacle to accessing healthcare for women?.
      Approximately one-quarter of respondents indicated that they would conscientiously object to providing anaesthesia for termination of pregnancy, similar to the proportion of general practitioners who objected.
      This issue includes a number of research studies that is specific to women cohorts.
      • Fu F.
      • Xiao F.
      • Chen W.
      • et al.
      A randomised double-blinded dose-response study of weight-adjusted infusions of noradrenaline for preventing hypotension during combined spinal–epidural anaesthesia for Caesarean delivery.
      • Singh P.
      • Singh N.
      • Reschke M.
      • Ngan Kee W.
      • Palanisamy A.
      • Monks D.
      Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes.
      • Aho T.
      • Harno H.
      • Lipsanen J.
      • Kalso E.
      Analgesia nociception index as a phenotypic marker for cardiac autonomic activity during cold pressor test in women treated for breast cancer.
      • Komatsu R.
      • Ando K.
      • Flood P.
      Factors associated with persistent pain after childbirth – a narrative review.
      Caesarean delivery is the most common major surgical procedure performed worldwide, and spinal anaesthesia is the most common anaesthetic for these procedures. One clinical study
      • Fu F.
      • Xiao F.
      • Chen W.
      • et al.
      A randomised double-blinded dose-response study of weight-adjusted infusions of noradrenaline for preventing hypotension during combined spinal–epidural anaesthesia for Caesarean delivery.
      and one network meta-analysis
      • Singh P.
      • Singh N.
      • Reschke M.
      • Ngan Kee W.
      • Palanisamy A.
      • Monks D.
      Vasopressor drugs for the prevention and treatment of hypotension during neuraxial anaesthesia for Caesarean delivery: a Bayesian network meta-analysis of fetal and maternal outcomes.
      address spinal anaesthesia-induced hypotension in this surgical population. A narrative review summarises studies of persistent pain after childbirth and identifies gaps in current knowledge.
      • Komatsu R.
      • Ando K.
      • Flood P.
      Factors associated with persistent pain after childbirth – a narrative review.
      The authors suggest research strategies to close these gaps and identify interventions to decrease the incidence of persistent postpartum pain. Aho and colleagues
      • Aho T.
      • Harno H.
      • Lipsanen J.
      • Kalso E.
      Analgesia nociception index as a phenotypic marker for cardiac autonomic activity during cold pressor test in women treated for breast cancer.
      investigated autonomic nervous system function profiles during the cold pressor test as a possible biomarker for pain phenotypes in women with breast cancer. A 25-year review of a large Quebec, Canada database found an association between maternal exposure to general anaesthesia during the first trimester and central nervous system defects, particularly microcephaly, in offspring.
      • Auger N.
      • Ayoub A.
      • Piché N.
      First trimester general anaesthesia and risk of central nervous system defects in offspring.
      There is concerning preclinical evidence of anaesthesia-induced developmental neurotoxicity, but whether early human exposure to anaesthesia (in utero or in early life) contributes adversely to human development remains to be determined. In a thought-provoking review of this translational research, Cabrera and colleagues
      • Cabrera O.
      • Gulvezan T.
      • Symmes B.
      • Quillinan N.
      • Jevtovic-Todorovic V.
      Sex differences in neurodevelopmental abnormalities caused by early life anaesthesia exposure: a review.
      summarise emerging evidence that neurotoxicity may occur differentially in female and male rat models of anaesthesia-induced neurotoxicity. This finding should not be surprising, given our knowledge of the influence of sex on many aspects of health, including responses to drugs. However, it serves to emphasise that we must take sex and gender into account in future research.
      • Leslie K.
      • Kasza J.
      Sex and gender inclusion, analysis and reporting in anaesthesia research.
      In conclusion, women anaesthesiologists, educators, and researchers are critical to the profession and to the health of our patients, both women and men. Women professionals and women patients have many similar, yet many different, characteristics and attributes than men. Women anaesthesiologists act and respond differently to their work environments, and women patients respond differently to their anaesthetic and treatment plans. It is our responsibility to recognise, study, adapt to, and celebrate these differences.

      Authors' contributions

      Drafting of the manuscript: CAW, CB, JMH.
      Editing of manuscript: SRM, HCH.
      Final approval of the manuscript: CAW, CB, JMH, SRM, HCH.

      Declarations of interest

      CAW is a member of the editorial board of the BJA. SRM has no interests to declare. CB is an editor of the BJA. HCH is editor-in-chief of the BJA. JMH was editor-in-chief of the BJA from 1997–2005 and chair of the BJA board from 2006 to 2012.

      Funding

      Department of Anesthesia at the University of Iowa , Iowa City, IA, USA.

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