literature review on gender bias

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• Published: 22 September 2020

Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice

• Lorena Alcalde-Rubio 1 ,
• Ildefonso Hernández-Aguado 1 , 2 ,
• Lucy Anne Parker 1 , 2 ,
• Eduardo Bueno-Vergara 1 &
• Elisa Chilet-Rosell   ORCID: orcid.org/0000-0002-9091-7255 1 , 2  

International Journal for Equity in Health volume  19 , Article number:  166 ( 2020 ) Cite this article

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Introduction

Gender, understood as “social relationships between males and females in terms of their roles, behaviours, activities, attributes and opportunities, and which are based on different levels of power”, [ 1 ] is one of the main social determinants of health [ 2 ]. The damage caused to population health by gender inequality across the globe is immense and justifies comprehensive actions addressing gender equity in health at all levels [ 3 ]. In the words of Hawkes and Buse, “Now is the time to take the call from Alma Ata in its literal sense—“Health is for All” not only for some. Embedding of gender in global health provides one promising route to attainment of the longstanding, but long-languishing, human right—the right to health” [ 4 ]. The root causes of gender inequality encompass all societal spheres and a multisectoral approach is required [ 5 ]. In fact, it has been shown that actions across multiple sectors in low and middle-income countries can improve a variety of health and development outcomes [ 6 ]. Therefore, there is no doubt that gender mainstreaming should pervade all policies. The UN Economic and Social Council embraced this approach in 1997 as “assessing the implications for women and men of any planned action, including legislation, policies, or programmes … so that women and men benefit equally, and inequality is not perpetuated” [ 7 ]. On global level, the impact of gender inequality on health was later included in the UN’s the Millennium Development Goals, and remains significant in the Sustainable Development Goals [ 8 ].

In the health domain, there has been a substantial interest in gender issues in the last two decades. Vlassof and García Montero explained why gender is key to understanding all dimensions of health including healthcare, health seeking behaviour and health status. Consequently, they proposed transformation in all areas of the health sector in order to integrate gender perspective [ 9 ]. This integral change should encompass actions on policy, research, training and programmes including interventions at the individual level. We have witnessed an appreciable increase in the consideration of gender in health plans [ 5 , 10 ] and particularly in those focused on women’s reproductive health [ 11 , 12 ]. However, more than 20 years of research from high-income, middle income and low-income countries shows that gender inequalities remain embedded in health systems [ 13 , 14 ]. Within health care systems, unconscious gender biases –based on gender stereotypes- and sexism affect patient care [ 15 , 16 ]. While policy and organisational changes are essential, the involvement of health workers can act as a catalyst of integral change in the healthcare system.

Since the recognition of gender bias in the clinical management of cardiovascular disease, [ 17 , 18 , 19 ] several other health problems have been the target of research, which shows the extent of gender inequity in health care. Last year, Nature Communications published a study analysing health data for almost 7 million men and women in the Danish healthcare system over a 21-year period, and showing that women were diagnosed later than men in more than 700 diseases [ 20 ]. Despite demonstrated disparities in women’s health and advocacy to improve women’s health, there is still a lack of patient centred care for women.

These contributions from research on the relevance of gender inequalities in health care have not gone along with research on effective interventions that could provide health workers with practical tools that facilitate the application of gender oriented clinical interventions. In addition, the lack of patient centred care for women has been reported recently [ 21 , 22 , 23 ]. In fact, Celik et al.’s 2010 review of the available literature, [ 24 ] the authors failed to find references that contributed to the development of procedures to increase health professionals’ skills related to gender. Health systems and health providers remain largely gender unresponsive [ 13 ]. In order to move forward we need to assess the available experience in reducing gender-based inequities and, where possible, learn how to scale-up effective interventions. Our objective here is to identify available tools that can be used to overcome or reduce gender bias in clinical practice.

Material and methods

This scoping review was developed following the Arksey and O’Malley’s methodological framework, which we used to guide our reporting where possible [ 25 ]. We specifically searched for articles examining interventions to reduce or prevent gender bias in clinical practice, as long as they were provider-focused and healthcare-based.

Search strategy

The primary search was performed in Medline through PubMed, Web of Science, Scielo and Lilacs. Modifications on our search strategy in Medline through PubMed were made several times to ensure highest sensitivity. Finally, we decided to combine two individual searches to expand our search in Pubmed and we then made minor modifications to adequate the search strategy to each database. The final search strategies combined Subject headings and MeSH terms related to “gender”, “healthcare”, “bias”, “disparities”,“inequality”,“inequity” and “intervention” (Table  1 ).

In order to retrieve as many interventions studies as possible, we applied no date limitations and retrieved all results published until December 2018.

Study selection

We included empirical studies designed to prevent or decrease gender bias in clinical practice and those that were focused on other types of prejudice (such as race, age …) as long as they also evaluated gender bias. Similarly, we included studies designed to evaluate the effect on gender bias of interventions already implemented for a different primary objective (e.g. improving adherence to guidelines). These interventions should be provider-focused and healthcare-based. We only included studies that evaluated the interventions. Given the heterogeneity in the evaluation of gender bias, we included studies that assessed or measured any outcome related to clinical practice in a gender-disaggregated way (e.g. in-hospital adverse events) or the effects of interventions designed to reduce gender-based vulnerability of specific population (LGBTI+ populations, women suffering from intimate partner violence). We only included studies that were published in peer-review journals in English, Spanish and Portuguese. Exclusion criteria included non-empirical or descriptive studies, interventions focused only on patients and description of programmes or interventions without an evaluation of the impact.

All search results were first screened based on title and abstract by two researchers. The full text of potentially useful records was reviewed. We read all potentially useful texts and their reference lists were also revised for additional interventions. A detailed flow diagram of study selection is showed in Fig.  1 .

Flow diagram for identification of interventions to reduce gender bias in clinical practice

Data extraction and synthesis

We carried out the data extraction using a standardized data extraction form. Data were collected on the health issue, country, description of intervention (later categorized in clinical decision support guidelines and standardized protocols; interventions that included staff, clinic and community interventions; interventions managed by an all women team for female patients; gender sensitive improvements in data collection, and routine screening for gender violence), type of evaluation (considering the comparison group and the use of routine or non-routine-data) clinical setting (hospital, specialized care, primary health care, and others), main results and conclusions (later classified as successful or partially successful and not successful).

In order to evaluate the application of gender perspective in research reporting, we used the SAGER guidelines checklist adapted to our data extraction form [ 26 ]. In this case, we obtained information from the following items: introduction (explanation on whether sex and/or gender differences may be expected); methods (explanation on how sex and gender were taken into account in the design of the study, whether they ensured adequate representation of males and females, and justification of the reasons for any exclusion of males or females); results (in addition to sex-disaggregated data, it includes variables that facilitate gender analysis); and, discussion (implications of sex and gender on the study results and discussion of the implications of the results stratified by sex or from gender perspective).

Firstly, we performed an initial analysis of five papers by two researchers in order to homogenize data coding. Researchers agreed in four papers. After consensus on the assessment of the main variables, we proceed with the remaining articles. For the second set of articles, two researchers extracted data independently. A third research was in charge of detect discrepancies between researchers. Discrepancies were detected in four papers and were solved by consensus between the two researchers that reviewed each paper. Those discrepancies were related to minor variations on the length of text extracted to justify their answers and did not influence the interpretation of the results.

We performed a descriptive analysis of the information obtained from items formerly described.

After removing duplicates, we screened 3082 abstracts retrieved through database search. Additional file 1 : Appendix 1 presents detailed information of the 22 [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ] studies included in our scoping review.

When reporting the interventions, information regarding sex differences and the gender perspective: two of the studies failed to include whether sex and/or gender may be an important variant of the health outcome assessed in the introduction section (9%), three of the studies failed to report how the researchers ensured adequate representation of males and females in the sample (14%), in nine of them lacked variables/information that enabled a gender-based analysis (40%). Five studies did not discuss sex differences or apply a gender perspective (23%) and six did not discuss the implications of the results from a gender perspective (27%) (Table  2 ).

The interventions analysed were mainly focused on cardiovascular disease ( n  = 13, 59%) and, sexual and reproductive health, including one intervention focused on sexual orientation and gender identity ( n  = 5, 23%). Other themes were gender-based violence ( n  = 1), unhealthy drinking (n = 1), diabetes (n = 1) and renal failure (n = 1) (Table  3 ). Seventeen studies were conducted in USA (77%); the others were located in Brazil ( n  = 2), India (n = 1), Tanzania (n = 1) and Singapore (1).

Interventions were conducted more frequently in hospitals ( n  = 14, 64%). We found several types of intervention. Most studies included clinical decision support decision support guidelines and standardized protocols (15, 68%). These studies were aimed to reduce variability in healthcare and were not specifically designed to reduce gender bias. There was a cluster of studies (5) related to the program in the United States called Get with the Guidelines (GWTG) [ 49 ]. This initiative was focused on the redesign of hospital systems in order to improve the quality of patients care and was based on a collaborative model and Internet-based Patient Management. The GWTG included interactive learning sessions, teleconferences, and electronic communication between multidisciplinary teams from hospitals in a variety of settings to facilitate the transfer of the “how-to”, which is considered necessary to produce system-wide change. Finally, there were interventions that included activities involving staff, clinic, and community interventions (3, 14%), two studies evaluated data collection in a more gender-sensitive way, one more was an intervention managed by an all women team for female patients (2, 9%), and finally one study evaluated the implementation of gender violence screening.

The evaluations of the interventions were mostly conducted without comparison group and using routine data (7, 32%) or with a pre and post comparison and using routine data (6, 27%). The other 9 studies used non routine data (quantitative, qualitative and mixed data) and a variety of designs: randomised control group (2, 9%), non- randomised control group (2, 9%), without comparison group (3, 14%) and pre-post comparison (2, 9%).

The majority of the interventions (19, 86%) were mostly successful in narrowing the gender gap (See Annex 1 for more details). Four of them were unable to narrow this gap in all outcomes. There was no difference in cardiovascular events, quality of life, knowledge, attitudes and practices in women with cardiovascular disease after intervention [ 42 ]. A discharge tool was less used in women after acute myocardial infarction than in men [ 38 ].. Fewer women than men with heart failure received hospital discharge instructions and the length of the stay was longer for women even after implementation [ 32 ]. Additionally, the gender violence screening raised doubts in clinicians [ 39 ]. On the other hand, three studies were not successful in any outcome: two interventions in cardiovascular disease [ 36 , 43 ] and one in unhealthy drinking [ 48 ]. The latter one stated that a non-gender-specific threshold for an intervention in alcohol misuse was detrimental as may increase gender differences in receipt of brief intervention among patients.

Despite the extensive and growing evidence of gender bias in clinical practice published in scientific journals since the 90s, our scoping review has shown that few studies have tried to tackle this bias. After screening over 3082 abstracts in health sciences databases, we identified only 22 evaluated provider-focused and healthcare-based interventions. Most of the analysed studies focused on cardiovascular diseases and were strategies to improve adherence to existing guidelines in order to reduce variability in healthcare. It is noteworthy that even though the studies included in our scoping review described interventions that could reduce gender bias in clinical practice, we identified shortcomings in the reporting of the information from a gender perspective. Most of the interventions were successful in narrowing the gender gap in at least one of the outcomes even when they were not intended or seeking to reduce the gender gaps. Therefore, it is likely that future innovative interventions designed according to the theoretical bases that originate gender bias could result in higher reductions on gender bias.

There are, however, some limitations in our study. Firstly, the difficulty to find suitable articles, which we addressed by redefining our search and inclusion criteria several times in order to increase sensitivity. Secondly, the methodology of the studies was heterogeneous and could hinder the comparisons between studies. In addition, considering that some of the results of the analysed interventions were based on studies lacking a comparison group, interpretations should be cautious. Finally, interventions were conducted on few countries, which could difficult to replicate them in different contexts.

Although we identified few studies which sought to reduce gender bias in clinical practice, the interventions examined were mostly successful, demonstrating that narrowing gender gaps in healthcare is possible. This scoping review is a starting point, which, along with barriers and facilitators of interventions to reduce gender gap in healthcare already described in literature [ 24 ], can guide future interventions. The analysed interventions showed that gender disparities in healthcare could be reduced and even eliminated if clinician’s adherence to guidelines increased. Most of these interventions proposed the protocolization of technical procedures that aimed to reduce differences by sex and other variables without seeking specifically to reduce gender biases in health care - and may or may not result in that reduction. In contrast, interventions designed with the aim of reducing gender bias included different strategies (like programs managed by an all women team or improvement of the data collection system) and all of them were successful or partially successful in their objectives.

Most of the studies, particularly those focused on technical procedures, were based on specialized health care and hospitals. There is a lack of studies addressing this problem in primary healthcare (only two studies were based on this setting). If the narrowing of gender biases occurs in primary care, its impact could be even greater due to the volume of patients treated in these centres and because it is the patient’s first contact with the healthcare system [ 50 ].

Gender bias in clinical practice was described for the first time in the New England Journal of Medicine [ 17 , 18 , 19 ]. Almost 30 ago, Bernadine Healy used the term “Yentl syndrome” equating women with myocardial infarction to the character Yentl - a Jewish woman who dressed herself as a man to be able to study the sacred texts [ 18 ]. Healy was denouncing the fact that women have to show the same symptoms as men to receive the appropriate diagnosis and treatments, because the knowledge of cardiovascular disease was based on studies conducted on men. Since then, many studies have addressed gender bias in clinical practice, particularly in cardiovascular disease. In concordance with this, cardiovascular health was the predominant issue addressed in the analysed interventions. However, gender bias has been described in the clinical practice of a great number of diseases, [ 20 ] so it is necessary to expand the field of work to other health issues.

Importantly, physicians –and, the health system in general– have the potential to either reproduce or perpetuate disparities, or to overcome them. Even if the results of the interventions are encouraging, we need to question the theoretical framework in which these gender inequities originated. This may be why some interventions were not successful, as simply implementing instruments, while necessary, is not enough to tackle gender bias in professionals. It is important to advocate for reforms aimed to include gender aspects in the curricula of medical schools and in health research in order to advance in the field of gender- specific medicine [ 51 ].

Conclusions

In contrast to the wide research identifying gender bias in health care, few studies, so far, have described and evaluated interventions aimed to tackle this bias. However, there is some empirical evidence showing how to narrow the gender gaps in healthcare, as the reviewed literature reveals that that most of the interventions were successful at achieving at least one of the expected outcomes. Nevertheless, it is alarming that studies of interventions in primary healthcare, where the impact of narrowing of gender bias could be greater, are almost absent in the present available research.

Based on the results of our review, we consider that knowledge about the causes of gender inequities in healthcare should permeate new research on how to increase gender equity and improve quality in clinical practice.

Implications for practice and/or policy

Future clinical practice interventions should be developed with a gender perspective and should be comprehensive, long-term, experimental, evaluated with standardized methods, and specifically developed to tackle gender bias. In addition, they should address not only the women-man dichotomy, but also the gender continuum. Interventions should consider facilitators and barriers to include gender perspective in healthcare and they should always be adapted to the specific context, moment and population targeted. Finally, successful implementation is not enough, monitoring is essential. Standardized indicators and audits need to be developed for a structural embedding of gender in clinical practice.

Availability of data and materials

All available data is included in the publication.

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Acknowledgements

The authors thank Jonathan Whitehead and Jessica Gorlin for language editing.

This study was supported by CIBER in Epidemiology and Public Health. Funder had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

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LAL, IHA and ECR participated in the hypothesis and design of the study. EBV supported the bibliographic search. LAL, IHA, LAP and ECR participated in the collection, analysis and interpretation of data from identified articles. LAL and ECR have written the manuscript and all authors made important contributions to different drafts. All authors approve the final manuscript and its submission to this journal.

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Alcalde-Rubio, L., Hernández-Aguado, I., Parker, L.A. et al. Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice. Int J Equity Health 19 , 166 (2020). https://doi.org/10.1186/s12939-020-01283-4

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Research: How Bias Against Women Persists in Female-Dominated Workplaces

by Amy Diehl , Amber L. Stephenson and Leanne M. Dzubinski

Summary .   

New research examines gender bias within four industries with more female than male workers — law, higher education, faith-based nonprofits, and health care. Having balanced or even greater numbers of women in an organization is not, by itself, changing women’s experiences of bias. Bias is built into the system and continues to operate even when more women than men are present. Leaders can use these findings to create gender-equitable practices and environments which reduce bias. First, replace competition with cooperation. Second, measure success by goals, not by time spent in the office or online. Third, implement equitable reward structures, and provide remote and flexible work with autonomy. Finally, increase transparency in decision making.

It’s been thought that once industries achieve gender balance, bias will decrease and gender gaps will close. Sometimes called the “ add women and stir ” approach, people tend to think that having more women present is all that’s needed to promote change. But simply adding women into a workplace does not change the organizational structures and systems that benefit men more than women . Our new research (to be published in a forthcoming issue of Personnel Review ) shows gender bias is still prevalent in gender-balanced and female-dominated industries.

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• Published: 28 April 2020

The impact a-gender: gendered orientations towards research Impact and its evaluation

• J. Chubb   ORCID: orcid.org/0000-0002-9716-820X 1 &
• G. E. Derrick   ORCID: orcid.org/0000-0001-5386-8653 2  

Palgrave Communications volume  6 , Article number:  72 ( 2020 ) Cite this article

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A Correction to this article was published on 19 May 2020

This article has been updated

Using an analysis of two independent, qualitative interview data sets: the first containing semi-structured interviews with mid-senior academics from across a range of disciplines at two research-intensive universities in Australia and the UK, collected between 2011 and 2013 ( n  = 51); and the second including pre- ( n  = 62), and post-evaluation ( n  = 57) interviews with UK REF2014 Main Panel A evaluators, this paper provides some of the first empirical work and the grounded uncovering of implicit (and in some cases explicit) gendered associations around impact generation and, by extension, its evaluation. In this paper, we explore the nature of gendered associations towards non-academic impact (Impact) generation and evaluation. The results suggest an underlying yet emergent gendered perception of Impact and its activities that is worthy of further research and exploration as the importance of valuing the ways in which research has an influence ‘beyond academia’ increases globally. In particular, it identifies how researchers perceive that there are some personality traits that are better orientated towards achieving Impact; how these may in fact be gendered. It also identifies how gender may play a role in the prioritisation of ‘hard’ Impacts (and research) that can be counted, in contrast to ‘soft’ Impacts (and research) that are far less quantifiable, reminiscent of deeper entrenched views about the value of different ‘modes’ of research. These orientations also translate to the evaluation of Impact, where panellists exhibit these tendencies prior to its evaluation and describe the organisation of panel work with respect to gender diversity.

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Introduction.

The management and measurement of the non-academic impact Footnote 1 (Impact) of research is a consistent theme within the higher education (HE) research environment in the UK, reflective of a drive from government for greater visibility of the benefits of research for the public, policy and commercial sectors (Chubb, 2017 ). This is this mirrored on a global scale, particularly in Australia, where, at the ‘vanguard’ (Upton et al., 2014 , p. 352) of these developments, methods were first devised (but were subsequently abandoned) to measure research impact (Chubb, 2017 ; Hazelkorn and Gibson, 2019 ). What is broadly known in both contexts as an ‘Impact Agenda’—the move to forecast and assess the ways in which investment in academic research delivers measurable socio-economic benefit—initially sparked broad debate and in some instances controversy, among the academic community (and beyond) upon its inception (Chubb, 2017 ). Since then, the debate has continued to evolve and the ways in which impact can be better conceptualised and implemented in the UK, including its role in evaluation (Stern, 2016 ), and more recently in grant applications (UKRI, 2020 ) is robustly debated. Notwithstanding attempts to better the culture of equality and diversity in research, (Stern, 2016 ; Nature, 2019 ) in the broader sense, and despite the implementation of the Impact agenda being studied extensively, there has been very little critical engagement with theories of gender and how this translates specifically to more downstream gendered inequities in HE such as through an impact agenda.

The emergence of Impact brought with it many connotations, many of which were largely negative; freedom was questioned, and autonomy was seen to be at threat because of an audit surveillance culture in HE (Lorenz, 2012 ). Resistance was largely characterised by problematising the agenda as symptomatic of the marketisation of knowledge threatening traditional academic norms and ideals (Merton, 1942 ; Williams, 2002 ) and has led to concern about how the Impact agenda is conceived, implemented and evaluated. This concern extends to perceptions of gendered assumptions about certain kinds of knowledge and related activities of which there is already a corpus of work, i.e., in the case of gender and forms of public engagement (Johnson et al., 2014 ; Crettaz Von Roten, 2011 ). This paper explores what it terms as ‘the Impact a-gender’ (Chubb, 2017 ) where gendered notions of non-academic, societal impact and how it is generated feed into its evaluation. It does not wed itself to any feminist tradition specifically, however, draws on Carey et al. ( 2018 ) to examine, acknowledge and therefore amend how the range of policies within HE and how implicit power dynamics in policymaking produce gender inequalities. Instead, an impact fluidity is encouraged and supported. For this paper, this means examining how the impact a-gender feeds into expectations and the reward of non-academic impact. If left unchecked, the propagation of the impact a-gender, it is argued, has the potential to guard against a greater proportion of women generating and influencing the use of research evidence in public policy decision-making.

Scholars continue to reflect on ‘science as a gendered endeavour’ (Amâncio, 2005 ). The extensive corpus of historical literature on gender in science and its originators (Merton, 1942 ; Keller et al., 1978 ; Kuhn, 1962 ), note the ‘pervasiveness’ of the ‘masculine’ and the ‘objective and the scientific’. Indeed, Amancio affirmed in more recent times that ‘modern science was born as an exclusively masculine activity’ ( 2005 ). The Impact agenda raises yet more obstacles indicative of this pervasiveness, which is documented by the ‘Matthew’/‘Matilda’ effect in Science (Merton, 1942 ; Rossiter, 1993 ). Perceptions of gender bias (which Kretschmer and Kretschmer, 2013 hypothesise as myths in evaluative cultures) persist with respect to how gender effects publishing, pay and reward and other evaluative issues in HE (Ward and Grant, 1996 ). Some have argued that scientists and institutions perpetuate such issues (Amâncio, 2005 ). Irrespective of their origin, perceptions of gendered Impact impede evaluative cultures within HE and, more broadly, the quest for equality in excellence in research impact beyond academia.

To borrow from Van Den Brink and Benschop ( 2012 ), gender is conceptualised as an integral part of organisational practices, situated within a social construction of feminism (Lorber, 2005 ; Poggio, 2006 ). This article uses the notion of gender differences and inequality to refer to the ‘ hierarchical distinction in which either women and femininity and men and masculinity are valued over the other ’ (p. 73), though this is not precluding of individual preferences. Indeed, there is an emerging body of work focused on gendered associations not only about ‘types’ of research and/or ‘areas and topics’ (Thelwall et al., 2019 ), but also about what is referred to as non-academic impact. This is with particular reference to audit cultures in HE such as the Research Excellence Framework (REF), which is the UK’s system of assessing the quality of research (Morley, 2003 ; Yarrow and Davies, 2018 ; Weinstein et al., 2019 ). While scholars have long attended to researching gender differences in relation to the marketisation of HE (Ahmed, 2006 ; Bank, 2011 ; Clegg, 2008 ; Gromkowska-Melosik, 2014 ; Leathwood et al., 2008 ), and the gendering of Impact activities such as outreach and public engagement (Ward and Grant, 1996 ), there is less understanding of how far academic perceptions of Impact are gendered. Further, how these gendered tensions influence panel culture in the evaluation of impact beyond academia is also not well understood. As a recent discussion in the Lancet read ‘ the causes of gender disparities are complex and include both distal and proximal factors ’. (Lundine et al., 2019 , p. 742).

This paper examines the ways in which researchers and research evaluators implicitly perceive gender as related to excellence in Impact both in its generation and in its evaluation. Using an analysis of two existing data sets; the pre-evaluation interviews of evaluators in the UK’s 2014 Research Excellence Framework and interviews with mid-senior career academics from across the range of disciplines with experience of building impact into funding applications and/ or its evaluation in two research-intensive universities in the UK and Australia between 2011 and 2013, this paper explores the implicitly gendered references expressed by our participants relating to the generation of non-academic, impact which emerged inductively through analysis. Both data sets comprise researcher perceptions of impact prior to being subjected to any formalised assessment of research Impact, thus allowing for the identification of unconscious gendered orientations that emerged from participant’s emotional and more abstract views about Impact. It notes how researchers use loaded terminology around ‘hard’, and ‘soft’ when conceptualising Impact that is reminiscent of long-standing associations between epistemological domains of research and notions of masculinity/femininity. It refers to ‘hard’ impact as those that are associated with meaning economic/ tangible and efficiently/ quantifiably evaluated, and ‘soft’ as denoting social, abstract, potentially qualitative or less easily and inefficiently evaluated. By extending this analysis to the gendered notions expressed by REF2014 panellists (expert reviewers whose responsibility it is to review the quality of the retrospective impact articulated in case studies for the purposes of research evaluation) towards the evaluation of Impact, this paper highlights how instead of challenging these tendencies, shared constructions of Impact and gendered productivity in academia act to amplify and embed these gendered notions within the evaluation outcomes and practice. It explores how vulnerable seemingly independent assessments of Impact are to these widespread gendered- associations between Impact, engagement and success. Specifically, perceptions of the excellence and judgements of feasibility relating to attribution, and causality within the narrative of the Impact case study become gendered.

The article is structured as follows. First, it reviews the gender-orientations towards notions of ‘hard’ and ‘soft’ excellence in forms of scholarly distinction and explores how this relates to the REF Impact evaluation criteria, and the under-representation of women in the academic workforce. Specifically, it hypothesises the role of how gendered notions of excellence that construct academic identities contribute to a system that side-lines women in academia. This is despite associating the generation of Impact as a feminised skill. We label this as the ‘Impact a-gender’. The article then outlines the methodology and how the two, independent databases were combined and convergent themes developed. The results are then presented from academics in the UK and Australia and then from REF2014 panellists. This describes how the Impact a-gender currently operates through academic cultural orientations around Impact generation, and in its evaluation through peer-review panels by members of this same academic culture. The article concludes with a recommendation that the Impact a-gender be explored more thoroughly as a necessary step towards guiding against gender- bias in the academic evaluation, and reward system.

Literature review

Notions of impact excellence as ‘hard’ or ‘soft’.

Scholars have long attempted to consider the commonalities and differences across certain kinds of knowledge (Becher, 1989 , 1994 ; Biglan, 1973a ) and attempts to categorise, divide and harmonise the disciplines have been made (Biglan, 1973a , 1973b ; Becher, 1994 ; Caplan, 1979 ; Schommer–Aikins et al., 2003 ). Much of this was advanced with a typology of the disciplines from (Trowler, 2001 ), which categorised the disciplines as ‘hard’ or ‘soft’. Both anecdotally and in the literature, ‘soft’ science is associated with working more with people and less with ‘things’ (Cassell, 2002 ; Thelwall et al., 2019 ). These dichotomies often lead to a hierarchy of types of Impact and oppose valuation of activities based on their gendered connotations.

Biglan’s system of classifying disciplines into groups based on similarities and differences denotes particular behaviours or characteristics, which then form part of clusters or groups—‘pure’, ‘applied’, ‘soft’, ‘hard’ etc. Simpson ( 2017 ) argues that Biglan’s classification persists as one of the most commonly referred to models of the disciplines despite the prominence of some others (Pantin, 1968 ; Kuhn, 1962 ; Smart et al., 2000 ). Biglan ( 1973b ) classified the disciplines across three dimensions; hard and soft, pure and applied, life and non-life (whether the research is concerned with living things/organisms) . This ‘taxonomy of the disciplines’ states that ‘pure-hard’ domains tend toward the life and earth sciences,’pure-soft’ the social sciences and humanities, and ‘applied hard’ focus on engineering and physical science with ‘soft-applied’ tending toward professional practice such as nursing, medicine and education. Biglan’s classification looked at levels of social connectedness and specifically found that applied scholars Footnote 2 were more socially connected, more interested and involved in service activities, and more likely to publish in the form of technical reports than their counterparts in the pure (hard) areas of study. This resonates with how Impact brings renewed currency and academic prominence to applied researchers (Chubb, 2017 ). Historically, scholars inhabiting the ‘hard’ disciplines had a greater preference for research; whereas, scholars representing soft disciplines had a greater preference for teaching (Biglan, 1973b ). Further, Biglan ( 1973b ) also found that hard science scholars sought out greater collaborative efforts among colleagues when teaching as opposed to their soft science counterparts.

There are also long-standing gendered associations and connotations with notions of ‘hard’ and ‘soft’ (Storer, 1967 ). Typically used to refer to skills, but also used heavily with respect to the disciplines and knowledge domains, gendered assumptions and the mere use of ‘hard’ or ‘soft’ to describe knowledge production carries with it assumptions, which are often noted in the literature; ‘ we think of physics as hard and of political science as soft ’, Storer explains, adding how ‘hard seems to imply tough, brittle, impenetrable and strong, while soft on the other hand calls to mind the qualities of weakness, gentleness and malleability’ (p. 76). As described, hard science is typically associated with the natural sciences and quantitative paradigms whereas normative perceptions of feminine ‘soft’ skills or ‘soft’ science are often equated with qualitative social science. Scholars continue to debate dichotomised paradigms or ‘types’ of research or knowledge (Gibbons, 1999 ), which is emblematic of an undercurrent of epistemological hierarchy of the value of different kinds of knowledge. Such debates date back to the heated back and forth between scholars Snow (Snow, 2012 ) and literary critic Leavis who argued for their own ‘cultures’ of knowledge. Notwithstanding, these binary distinctions do few favours when gender is then ascribed to either knowledge domain or related activity (Yarrow and Davies, 2018 ). This is particularly pertinent in light of the current drive for more interdisciplinary research in the science system where there is also a focus on fairness, equality and diversity in the science system.

Academic performance and the Impact a-gender

Audit culture in academia impacts unfairly on women (Morley, 2003 ), and is seen as contributory to the wide gender disparities in academia, including the under-representation of women as professors (Ellemers et al., 2004 ), in leadership positions (Carnes et al., 2015 ), in receiving research acknowledgements (Larivière et al., 2013 ; Sugimoto et al., 2015 ), or being disproportionately concentrated in non-research-intensive universities (Santos and Dang Van Phu, 2019 ). Whereas gender discrimination also manifests in other ways such as during peer review (Lee and Noh, 2013 ), promotion (Paulus et al., 2016 ), and teaching evaluations (Kogan et al., 2010 ), the proliferation of an audit culture links gender disparities in HE to processes that emphasise ‘quantitative’ analysis methods, statistics, measurement, the creation of ‘experts’, and the production of ‘hard evidence’. The assumption here is that academic performance and the metrics used to value, and evaluate it, are heavily gendered in a way that benefits men over women, reflecting current disparities within the HE workforce. Indeed, Morely (2003) suggests that the way in which teaching quality is female dominated and research quality is male dominated, leads to a morality of quality resulting in the larger proportion of women being responsible for student-focused services within HE. In addition, the notion of ‘excellence’ within these audit cultures implicitly reflect images of masculinity such as rationality, measurement, objectivity, control and competitiveness (Burkinshaw, 2015 ).

The association of feminine and masculine traits in academia (Holt and Ellis, 1998 ), and ‘gendering its forms of knowledge production’ (Clegg, 2008 ), is not new. In these typologies, women are largely expected to be soft-spoken, nurturing and understanding (Bellas, 1999 ) yet often invisible and supportive in their ‘institutional housekeeping’ roles (Bird et al., 2004 ). Men, on the other hand are often associated with being competitive, ambitious and independent (Baker, 2008 ). When an individual’s behaviour is perceived to transcend these gendered norms, then this has detrimental effects on how others evaluate their competence, although some traits displayed outside of these typologies go somewhat ‘under the radar’. Nonetheless, studies show that women who display leadership qualities (competitiveness, ambition and decisiveness) are characterised more negatively than men (Rausch, 1989 ; Heilman et al., 1995 ; Rossiter, 1993 ). Incongruity between perceptions of ‘likeability’ and ‘competence’ and its relationship to gender bias is present in evaluations in academia, where success is dependent on the perceptions of others and compounded within an audit culture (Yarrow and Davis, 2018). This has been seen in peer review, reports for men and women applicants, where women were disadvantaged by the same characteristics that were seen as a strength on proposals by men (Severin et al., 2019 ); as well as in teaching evaluations where women receive higher evaluations if they are perceived as ‘nurturing’ and ‘supportive’ (Kogan et al., 2010 ). This results in various potential forms of prejudice in academia: Where traits normally associated with masculinity are more highly valued than those associated with femininity (direct) or when behaviour that is generally perceived to be ‘masculine’ is enacted by a woman and then perceived less favourably (indirect/ unconscious). That is not to mention direct sexism, rather than ‘through’ traits; a direct prejudice.

Gendered associations of Impact are not only oversimplified but also incredibly problematic for an inclusive, meaningful Impact agenda and research culture. Currently, in the UK, the main funding body for research in the UK, UK Research and Innovation (UKRI) uses a broad Impact definition: ‘ the demonstrable contribution that excellent research makes to society and the economy ’ (UKRI website, 2019 ). The most recent REF, REF2014, Impact was defined as ‘ …an effect on, change or benefit to the economy, society, culture, public policy or services, health, the environment or quality of life, beyond academia ’. In Australia, the Australian Research Council (ARC) proposed that researchers should ‘embed’ Impact into the research process from the outset. Both Australia and the UK have been engaged in policy borrowing around the evaluation of societal impact and share many similarities in approaches to generating and evaluating it. Indeed, Impact has been deliberately conceptualised by decision-makers, funders and governments as broad in order to increase the appearance of being inclusivity, to represent a broad range of disciplines, as well as to reflect the ‘diverse ways’ that potential beneficiaries of academic research can be reached ‘beyond academia’. The adoption of societal impact as a formalised criterion in the evaluation of research excellence was initially perceived to be potentially beneficial for women, due to its emphasis on concepts such as ‘public engagement’; ‘duty’ and non-academic ‘cooperation/collaboration’ (Yarrow and Davies, 2018 ). In addition, the adoption of narrative case studies to demonstrate Impact, rather than adopting a complete metrics-focused exercise, can also be seen as an opportunity for women to demonstrate excellence in the areas where they are over-represented, such as teaching, cultural enrichment, public engagement (Andrews et al., 2005 ), informing public policy and improving public services (Schatteman, 2014 ; Wheatle and BrckaLorenz, 2015). However, despite this, studies highlight how for the REF2014, only 25% of Impact Case Studies for business and management studies were from women (Davies et al., 2020 ).

With respect to Impact evaluation, previous research shows that there is a direct link between notions of academic culture, and how research (as a product of that culture) is valued and evaluated (Leathwood and Reid, 2008 ; p. 120). Geertz ( 1983 ) argues that academic membership is a ‘cultural frame that defines a great part of one’s life’ influences belief systems around how academic work is orientated. This also includes gendered associations implicit in the academic reward system, which in turn influences how academics believe success is to be evaluated, and in what form that success emerges. This has implications in how academic associations of the organisation of research work and the ongoing constructions of professional identity relative to gender, feeds into how these same academics operate as evaluators within a peer review system evaluation. In this case, instead of operating to challenge these tendencies, shared constructions of gendered academic work are amplified to the extent that they unconsciously influence perceptions of excellence and the judgements of feasibility as pertaining to the attribution and causality of the narrative argument. As such, in an evaluation of Impact with its ambiguous definition (Derrick, 2018 ), and the lack of external indicators to signal success independent of cultural constructions inherent in the panel membership, effects are assumed to be more acute. In this way, this paper argues that the Impact a-gender can act to further disadvantage women.

The research combines two existing research data sets in order to explore implicit notions of gender associated with the generation and evaluation of research Impact beyond academia. Below the two data sets and the steps involved in analysing and integrating findings are described along with our theoretical positioning within the feminist literature Where verbatim quotation is used, we have labelled the participants according to each study highlighting their role and gender. Further, the evaluator interviews specify the disciplinary panel and subpanel to which they belonged, as well as their evaluation responsibilities such as: ‘Outputs only’; ‘Outputs and Impact’; and ‘Impacts only’.

Analysis of qualitative data sets

This research involved the analysis and combination of two independently collected, qualitative interview databases. The characteristics and specifics of both databases are outlined below.

Interviews with mid-senior academics in the UK and Australia

Fifty-one semi-structured interviews were conducted between 2011 and 2013 with mid-senior academics at two research-intensive universities in Australia and the UK. The interviews were 30–60 min long and participants were sourced via the research offices at both sites. Participants were contacted via email and invited to participate in a study concerning resistance towards the Impact agenda in the UK and Australia and were specifically asked for their perceptions of its relationship with freedom, value and epistemic responsibility and variations across discipline, career stage and national context. Mostly focused on ex ante impact, some interviewees also described their experiences of Impact in the UK and Australia, in relation to its formal assessment as part of the Excellence Innovation Australia (EIA) for Australia and the Research Excellence Framework (REF) in the UK.

Participants comprised mid to senior career academics with experience of winning funding from across the range of disciplines broadly representative of the arts and humanities, social sciences, physical science, maths and engineering and the life and earth sciences. For the purposes of this paper, although participant demographic information was collected, the relationship between the gender of the participants, their roles, disciplines/career stage was not explicitly explored instead, such conditions were emergent in the subsequent inductive coding during thematic analysis. A reflexive log was collected in order to challenge and draw attention to assumptions and underlying biases, which may affect the author, inclusive of their own gender identity. Further information on this is provided in Chubb ( 2017 ).

Pre- and post-evaluation interviews with REF2014 evaluators

REF2014 in the UK represented the world’s first formalised evaluation of ex-post impact, comprising of 20% of the overall evaluation. This framework served as a unique experimental environment with which to explore baseline tendencies towards impact as a concept and evaluative object (Derrick, 2018 ).

Two sets of semi-structured interviews were conducted with willing participants: sixty-two panellists were interviewed from the UK’s REF2014 Main Panel A prior to the evaluation taking place; and a fifty-seven of these were re-interviewed post-evaluation. Main Panel A covers six Sub-panels: (1) Clinical Medicine; (2) Public Health, Health Services and Primary Care; (3) Allied Health Professions, Dentistry, Nursing and Pharmacy; (4) Psychology, Psychiatry and Neuroscience; (5) Biological Sciences; and (6) Agriculture, Veterinary and Food Sciences. Again, the relationship between the gender of the participants and their discipline is not the focus for the purposes of this paper.

Database combination and identification of common emergent themes

The inclusion of data sets using both Australian and UK researchers was pertinent to this study as both sites were at the cusp of implementing the evaluation of Impact formally. These researcher interviews, as well as the evaluator interviews were conducted prior to any formalised Impact evaluation took place, but when both contexts required ex ante impact in terms of certain funding allocation, meaning an analysis of these baseline perceptions between databases was possible. Further, the inclusion of the post-evaluation interviews with panellists in the UK allowed an exploration of how these gendered perceptions identified in the interviews with researchers and panellists prior to the evaluation, influenced panel behaviour during the evaluation of Impact.

Initially, both data sets were analysed using similar, inductive, grounded-theory-informed approaches inclusive of a discourse and thematic analysis of the language used by participants when describing impact, which allowed for the drawing out of metaphor (Zinken et al., 2008 ). This allowed data combination and analysis of the two databases to be conducted in line with the recommendations for data-synthesis as outlined in Weed ( 2005 ) as a form of interpretation. This approach guarded against the quantification of qualitative findings for the purposes of synthesis, and instead focused on an initial dialogic approach between the two authors (Chubb and Derrick), followed by a re-analysis of qualitative data sets (Heaton, 1998 ) in line with the outcomes of the initial author-dialogue as a method of circumventing many of the drawbacks associated with qualitative data-synthesis. Convergent themes from each, independently analysed data set were discussed between authors, before the construction of new themes that were an iterative analysis of the combined data set. Drawing on the feminist tradition the authors did not apply feminist standpoint theory, instead a fully inductive approach was used to unearth rich empirical data. An interpretative and inductive approach to coding the data using NVIVO software in both instances was used and a reflexive log maintained. The availability of both full, coded, qualitative data sets, as well as the large sample size of each, allowed this data-synthesis to happen.

Researcher’s perceptions of Impact as either ‘hard’ or ‘soft’

Both UK and Australian academic researchers (researchers) perceive a guideline of gendered productivity (Davies et al., 2017 ; Sax et al., 2002 ; Astin, 1978 ; Ward and Grant, 1996 ). This is where men or women are being dissuaded (by their inner narratives, their institutions or by colleagues) from engaging in Impact either in preference to other (more masculine) notions of academic productivity, or towards softer (for women) because they consider themselves and are considered by others to be ‘good at it’. Participants often gendered the language of Impact and introduced notions of ‘hard’ and ‘soft’. On the one hand, this rehearses and resurfaces long-standing views about the ‘Matthew Effect’ because often softer Impacts were seen as being of less value by participants, but also indicates that the word impact itself carries its own connotations, which are then weighed down further by more entrenched gender associations.

Our research shows that when describing Impact, it was not necessarily the masculinity or femininity of the researcher that was emphasised by participants, rather researchers made gendered presumptions around the type of Impact, or the activity used to generate it as either masculine or feminine. Some participants referred to their own research or others’ research as either ‘hard’ or as ‘soft and woolly’. Those who self-professed that their research was ‘soft’ or woolly’ felt that their research was less likely to qualify as having ‘hard’ impact in REF terms Footnote 3 ; instead, they claimed their research would impact socially, as opposed to economically; ‘ stuff that’s on a flaky edge — it’s very much about social engagement ’ (Languages, Australia, Professor, Male) . One researcher described Impact as ‘a nasty Treasury idea,’ comparing it to: a tsunami, crashing over everything which will knock out stuff that is precious ’ . (Theatre, Film and TV, UK, Professor, Male) . This imagery associates the concept of impact with force and weight (or hardness as mentioned earlier) particularly in disciplines where the effect of their research may be far more nuanced and subtle. One Australian research used force to depict the impact of teaching and claimed Impact was like a footprint, and teaching was ‘ a pretty heavy imprint ’ (Environment, UK, Professor, Male) . Participants characterised ‘force and weight’ as masculine, suggesting that some connotations of Impact and the associated activities may be gendered. The word ‘Impact’ was inherently perceived by many researchers as problematic, bound with linguistic connotations and those imposed by the official definitions, which in many cases are perceived as negative or maybe even gendered (Chubb, 2017 ): ‘ The etymology of a word like impact is interesting. I’ve always seen what I do as being a more subtle incremental engagement, relevance, a contribution ’. (Theatre, Film and TV, UK, Professor, Male) .

Researchers associated the word ‘impact’ with hard-ness, weight and force; ‘ anything that sorts of hits you ’ (Languages, UK, Senior Lecturer, Female) . One researcher suggested that Impact ‘ sounds kind of aggressive — the poor consumer! ’ (History, Australia, Professor, Female) . Talking about her own research in the performing arts, one Australian researcher commented: ‘ It’s such a pain in the arse because the Arts don’t fit the model. But in a way they do if you look at the impact as being something quite soft ’ (Music, Australia, Professor, Female) . Likewise, a similar comparison was seen by a female researcher from the mechanical engineering discipline: ‘ My impact case study wasn’t submitted mainly because I’m dealing with that slightly on the woolly side of things ’ (Mechanical Engineering, Australia, Professor, Female) . Largely, gender related comments hailed from the ‘hard’ science and from arts and humanities researchers. Social scientists commented less, and indeed, one levelled that Impact was perhaps less a matter of gender, and more a matter of ability (Chubb, 2017 ): ‘ It’s about being articulate! Both guys and women who are very articulate and communicate well are outward looking on all of these things ’ ( Engineering Education, Australia, Professor, Female).

Gendered notions of performativity were also very pronounced by evaluators who were assessing the outputs only, suggesting how these panel cultures are orientated around notions of gender and scientific outputs as ‘hard’ if represented by numbers. The focus on numbers was perceived by the following panellist as ‘ a real strong tendency particularly amongst the Alpha male types ’ within the panel that relate to findings about the association of certain traits—risk aversion, competitiveness, for example, with a masculinised market logic in HE;

And I like that a lot because I think that there is a real strong tendency particularly amongst the Alpha male types of always looking at the numbers, like the numbers and everything. And I just did feel that steer that we got from the panel chairs, both of them were men by the way, but they were very clear, the impact factors and citations and the rank order of a journal is this is information that can be useful, but it’s not your immediate first stop. (Panel 1, Outputs and Impact, Female)

However, a metric-dominant approach was not the result of a male-dominated panel environment and instead, to the panels credit, evaluators were encouraged not to use one-metric as the only deciding factor between star-rating of quality. However, this is not to suggest that metrics did not play a dominant role. In fact, in order to resolve arguments, evaluators were encouraged to ‘ reflect on these other metrics ’ (Panel 3, Outputs only, Male) in order to rectify arguments where the assessment of quality was in conflict. This use of ‘other metrics’ was preferential to a resolution of differences that are based on more ‘soft’ arguments that are based on understanding where differences in opinion might lie in the interpretation of the manuscript’s quality. Instead, the deciding factor in resolving arguments would be the responsibility, primarily, of a ‘hard’ concept of quality as dictated by a numerical value;

Read the paper, judge the quality, judge the originality, the rigour, the impact — if you have to because you’re in dispute with another assessor, then reflect on these other metrics. So I don’t think metrics are that helpful actually if and until you’ve got a real issue to be able to make a decision. But I worry very much that metrics are just such a simple way of making the process much easier, and I’m worried about that because I think there’s a bit of game playing going on with impact factors and that kind of thing. (Panel 3, Outputs Only, Male)

Table 1 outlines the emergent themes, which, through inductive coding participants broadly categorised domains of research, their qualities and associations, types of activities and the gendered assumption generally made by participants when describing that activity. The table is intended only to provide an indicative overview of the overall tendencies of participants toward certain narratives as is not exhaustive, as well as a guide to interpret the perceptions of Impact illustrated in the below results.

Table one describes the dichotomous views that seemed to emerge from the research but it’s important to note that researchers associated Impact as related to gender in subtle, and in some cases overt ways. The data suggests that some male participants felt that female academics might be better at Impact, suggesting that female academics might find it liberating, linked it to a sense of duty or public service, implying that it was second nature. In addition, some male participants associated types of Impact domains as female-orientated activity and the reverse was the case with female and male-orientated ‘types’ of Impact. For example, at one extreme, a few male researchers seemed to perceive public engagement as something, which females would be particularly good at, generalising that they are not competitive ‘ women are better at this! They are less competitive! ’ (Environment, UK, Professor, Male) . Indeed, one male researcher suggested that competitiveness actually helps academics have an impact and does not impede it:

I get a huge buzz from trying to communicate those to a wider audience and winning arguments and seeing them used. It’s not the use that motivates me it’s the process of winning, I’m competitive! (Economics, UK, Professor, Male)

Analysis also revealed evidence that some researchers has gendered perceptions of Impact activities just as evaluators did. Here, women were more likely to promote the importance of engaging in Impact activities, whereas men were focused on producing indicators with hard, quantitative indicators of success. Some researchers implied that public engagement was not something entirely associated with the kinds of Impact needed to advance one’s career and for a few male researchers, this was accordingly associated with female academics. Certain female researchers in the sciences and the arts suggested similarly that there was a strong commitment among women to carry out public engagement, but that this was not necessarily shared by their male counterparts who, they perceived, undervalued this kind of work:

I think the few of us women in the faculty will grapple with that a lot about the relevance of what we’re doing and the usefulness, but for the vast majority of people it’s not there… [She implies that]…I think there is a huge gender thing there that every woman that you talk to on campus would consider that the role of the university is along the latter statement (*to communicate to the public). The vast majority of men would not consider that’s a role of the university. There’s a strong gender thing. (Chemical Engineering, Australia, Professor, Female)

Notwithstanding, it is important to distinguish between engagement and Impact. This research shows that participants perceive Impact activities to be gendered. There was a sense from one arts female researcher that women might be more interested in getting out there and communicating their work but that crucially, it is not the be-all and end- all of doing research: ‘ Women feel that there’s something more liberating, I can empathise with that, but that couldn’t be the whole job ’. Music, Australia, Professor, Female Footnote 4 . When this researcher, who was very much orientated towards Impact, asked if there were enough interviewees, she added ‘ mind you, you’ve probably spoken to enough men in lab coats ’. This could imply that inward-facing roles are associated with male-orientated activity and outward facing roles as perceived as more female orientated. Such sentiments perhaps relate to a binary delineation of women as more caring, subjective, applied and of men as harder, scientific and theoretical/ rational. This links to a broader characterisation of HE as marketised and potentially, more ‘male’ or at least masculinised—where increasing competitiveness, marketisation and performativity can be seen as linked to an increasingly macho way of doing business (Blackmore, 2002 ; Deem, 1998 ; Grummell et al., 2009 ; Reay, n.d. ). The data is also suggestive of the attitude that communication is a ‘soft’ skill and the interpersonal is seen as a less masculine trait. ‘ This is a huge generalisation but I still say that the profession is so dominated by men, undergraduates are so dominated by men and most of those boys will come into engineering because they’re much more comfortable dealing with a computer than with people ’ (Chemical Engineering, Australia, Professor, Female) . Again, this suggests women are more likely to pursue those scientific subjects, which will make a difference or contribute to society (such as nursing or environmental research, certainly those subjects that would be perceived as less ‘hard’ science domains).

There was also a sense that Impact activity, namely in this case public engagement and community work, was associated with women more than men by some participants (Amâncio, 2005 ). However, public engagement and certain social impact domains appeared to have a lower status and intellectual worth in the eyes of some participants. Some inferred that social and ‘soft’ impacts are seen as associated. With discipline. For instance, research concerning STEM (Science, Technology, Engineering and Medicine) subjects with females. They in turn may be held in low esteem. Some of the accounts suggest that soft impacts are perceived by women as not ‘counting’ as Impact:

‘ At least two out of the four of us who are female are doing community service and that doesn’t count, we get zero credit, actually I would say it gets negative credit because it takes time away from everything else ’. (Education Engineering, Australia, Professor, Female)

This was intimated again by another female UK computer scientist who claimed that since her work was on the ‘woolly side’ of things, and her impacts were predominantly in the social and public domain, she would not be taken seriously enough to qualify as a REF Impact case study, despite having won an award for her work:

‘ I don’t think it helps that if I were a male professor doing the same work I might be taken more seriously. It’s interesting, why recently? Because I’ve never felt that I’ve not been taken seriously because I’m a woman, but something happened recently and I thought, oh, you’re not taking me seriously because I’m a woman. So I think it’s a part ’. (Computer Science, UK, Professor, Female)

Researchers also connect the ‘hard’ and ‘soft’ associations with Impact described earlier to male and female traits. The relationship between Impact and gender is not well understood and it is not clear how much these issues are directly relatable to Impact or more symptomatic of the broader picture in HE. In order to get a broader picture, it is important to examine how these gendered notions of Impact translate into its evaluation. Some participants suggested that gender is a factor in the securing of grant money—certainly this comment reveals a local speculation that ‘the big boys’ get the grants, in Australia, at least: ‘ ARC grants? I’ve had a few but nothing like the big boys that get one after the other ,’ (Chemical Engineering, Australia, Professor, Female) . This is not dissimilar to the ‘alpha male’ comments from the evaluators described below who note a tendency for male evaluators to rely on ‘hard’ numbers whose views are further examined in the following section.

Gendered excellence in Impact evaluation

In the pre-evaluation interviews, panellists were asked about what they perceived to be ‘excellent’ research and ‘excellent’ Impact. Within this context, are mirrored conceptualisations of impacts as either ‘soft’ or ‘hard’ as was seen with the interviews with researchers described above. These conceptualisations were captured prior to the evaluation began. They can therefore be interpreted as the raw, baseline assumptions of Impact that are free from the effects of the panel group, showed that there were differences in how evaluators perceived Impact, and that these perceptions were gendered.

Although all researchers conceptualised Impact as a linear process for the purposes of the REF2014 exercise (Derrick, 2018 ), there was a tendency for female evaluators to be open to considering the complexity of Impact, even in a best-case scenario. This included a consideration that Impact as dictated within the narrative might have different indicators of value to different evaluators; ‘ I just think that that whole framing means that there is a form of normative standard of perfect impact ’ (Main Panel, Outputs and Impacts, Female) . This evaluator, in particular, went further to state how that their impression of Impact would be constructed from the comparators available during the evaluation;

‘ Given that I’m presenting impact as a good story, it would be like you saying to me; ‘Can you describe to me a perfect Shakespearean play?’…. well now of course, I can’t. You can give me lots of plays but they all have different kinds of interesting features. Different people would say that their favourite play was different. To me, if you’re taking interpretivist view, constructivist view, there is no perfect normative standard. It’s just not possible ’. (Panel 1, Outputs and Impacts, Female)

Female evaluators were also more sensitive to other complex factors influencing the evaluation of Impact, including time lag; ‘ …So it takes a long time for things like that to be accepted…it took hundreds of studies before it was generally accepted as real ’ (Panel 1, Outputs and Impacts, Female ); as well as the indirect way that research influences policy as a form of Impact;

‘ I don’t think that anything would get four stars without even blinking. I think that is impossible to answer because you have to look at the whole evidence in this has gone on, and how that does link to the impact that is being claimed, and then you would then have to look at how that impact, exactly how that research has impacted on the ways of the world, in terms of change or in terms of society or whatever. I don’t think you can see this would easily get four stars because of the overall process is being looked at, as well as the actual outcome ’ . (Panel 3, Outputs and Impact, Female)

Although these typologies were not absolute, there was a lack of complexity in the nuances around Impact. There was also heavily gendered language around Impacts as measurable, or not, that mirrored the association of Impact as being either ‘hard’, and therefore measurable, or ‘soft, and therefore more nuanced in value. In this way, male evaluators expressed Impact as a causal, linear event that occurred ‘ in a very short time ’ (P2, Outputs and Impact, Male) and involved a single ‘ star ’ (P3, Impacts only, Male) or ‘ impact champion ’ (Main Panel, Outputs and Impacts, Male) that drove it from start (research), to finish (Impact). These associations about Impact being ‘soft’ and ‘hard’ made by evaluators, mirror the responses from researchers in the above sections. In the example below, the evaluator used words such as ‘ strong ’ and ‘ big way ’ to describe Impact success, as well as emphasises causality in the argument;

‘ …if it has affected a lot of people or affected policy in a strong way or created change in a big way, and it can be clearly linked back to the research, and it’s made a difference ’. (Panel 2, Outputs and Impact, Male)

These perhaps show disciplinary differences as much as gendered differences. Further, there was a stronger tendency for male evaluators to strive towards conceptualisations of excellence in Impact as measurable or ‘ it’s something that is decisive and actionable ’ (Panel 6, Impacts, Male) . One male evaluator explained his conceptualised version of Impact excellence as ‘ straightforward ’ and therefore ‘ obviously four-star ’ due to the presence of metrics with which to measure Impact. This was a perception more commonly associated with male evaluators;

‘ …if somebody has been able to devise a — let’s say pancreatic cancer — which is a molecular cancer, which hasn’t made any progress in the last 40 years, and where the mortality is close to 100% after diagnosis, if someone devised a treatment where now suddenly, after diagnosis of pancreatic cancer, 90 percent of the people are now still alive 5 years later, where the mortality rate is almost 0%, who are alive after 5 years. That, of course, would be a dramatic, transformative impact ’. (Panel 1, Outputs and Impact, Male)

In addition, his tendency to seek various numeric indicators for measuring, and therefore assessing Impact (predominantly economic impact), as well as compressing its realisation to a small period of time ( ‘ suddenly ’ ) in a causal fashion, was more commonly expressed in male evaluators. This tendency automatically indicates the association of impacts as either ‘soft’ or ‘hard’ and divided along gendered norms, but also expresses Impact in monetary terms;

‘ Something that went into a patient or the company has pronounced with…has spun out and been taken up by a commercial entity or a clinical entity ’ (Panel 3, Outputs and Impacts, Male) , as well as impacts that are marketised; ‘ A new antimicrobial drug to market ’. (Panel 6, Outputs and Impact, Male) .

There was also the perception that female academics would be better at engagement (Johnson et al., 2014 ; Crettaz Von Roten, 2011 ) due to its link with notions of ‘ duty ’ (as a mother), ‘ engagement ’ and ‘ public service ’ are reflected in how female evaluators were also more open to the idea that excellent Impact is achieved through productive, ongoing partnerships with non-academic stakeholders. Here, the reflections of ‘duty’ from the evaluators was also mirrored by in interviews with researchers. Indeed, the researchers merged perceptions of parenthood, an academic career and societal impact generation. One female researcher drew on her role as a mother as supportive of her ability to participate in Impact generation, ‘ I have kids that age so… ’ (Biology, UK, Senior Lecturer, Female) . Indeed, parenthood emerged from researchers of both genders in relation to the Impact agenda. Two male participants spoke positively about the need to transfer knowledge of all kinds to society referencing their role as parents: ‘ I’m all for that. I want my kids to have a rich culture when they go to school ’ (Engineering, Australia, Professor, Male, E2) , and ‘ My children are the extension of my biological life and my students are an extension of my thoughts ’ (Engineering, Australia, Professor, Male, E1) . One UK female biologist commented that she indeed enjoys delivering public engagement and outreach and implies a reference to having a family as enabling her ability to do so: ‘ It’s partly being involved with the really well-established outreach work ,’ (Biology, UK, Senior Lecturer, Female) .

For the evaluators, the idea that ‘public service’ as second nature for female academics, was reflected in how female evaluators perceived the long, arduous and serendipitous nature of Impact generation, as well as their commitment to assessing the value of Impact as a ‘pathway’ rather than in line with impact as a ‘product’. Indeed, this was highlighted by one male evaluator who suggested that the measurement and assessment of Impact ‘ …needs to be done by economists ’ and that

‘ you [need] to put in some quantification one everything…[that] puts a negative value on being sick and a positive large value on living longer. So, yeah, the greatest impact would be something that saves us money and generates income for the country but something broad and improves quality of life ’. (Panel 2, Impacts, Male)

Since evaluators tend to exercise cognitive bias in evaluative situations (Langfeldt, 2006 ), these preconceived ideas about Impact, its generation and the types of people responsible for its success are also likely to permeate the evaluative deliberations around Impact during the peer review process. What is uncertain is the extent that these messages are dominant within the panel discourse, and therefore the extent that they influence the formation of a consensus within the group, and the ‘dominant definition’ of Impact (Derrick, 2018 ) that emerges as a result.

Notions of gender from the evaluators post-evaluation

Similar notions of gender-roles in academia pertaining to notions of scientific productivity were echoed by academics who were charged with its evaluation as part of the UK’s 2014 Research Excellence Framework. Interviews with evaluators revealed not only that the panel working-methods and characteristics about what constituted a ‘good’ evaluator were implicitly along gendered norms, but also that the assumed credit assumptions of performativity were also based on gender.

In assessments of the Impact criterion, an assessment that is not as amenable to quantitative representation requiring panels to conceptualise a very complex process, with unstandardised measures of significance and reach, there was still a gendered perception of Impact being ‘women’s work’ in academia. This perception was based on the tendency towards conceptualising Impact as ‘slightly grubby’ and ‘not very pure’, which echoes previously reported pre-REF2014 tensions that Impact is a task that an academic does when they cannot do real research (de Jong et al., 2015 );

But I would say that something like research impact is — it seems something slightly grubby. It’s not seen as not — by the academics, as not very pure. To some of them, it seems women’s work. Talking to the public, do you see what I mean? (Main Panel, Outputs and Impact, Female)

In addition, gendered roles also relate to how the panel worked with the assessment of Impact. Previous research has outlined how the equality and diversity assessment of panels for REF2014 were not conducted until after panellists were appointed (Derrick, 2018 ), leading to a lack of equal-representation of women on most panels. Some of the female panellists reflected that this resulted not only in a hyper-awareness of one’s own identity and value as a woman on the panel, but also implicitly associating the role that a female panellist would play in generating the evaluation. One panellist below, reflected that she was the only female in a male-dominated panel, and that the only other females in the room were the panel secretariat. The panellist goes further to explain how this resulted in a gendered-division of labour surrounding the assessment of Impact;

I mean, there’s a gender thing as well which isn’t directing what you’re talking about what you’re researching, but I was the only woman on the original appointed panel. The only other women were the secretariat. In some ways I do — there was initially a very gendered division of perspective where the women were all the ones aggregate the quantitative research, or typing it all up or talking about impact whereas the men were the ones who represented the big agenda, big trials. (Main Panel, Outputs and Impact, Female)

In addition, evaluators expressed opinions about what constituted a good and a bad panel member. From this, the evaluation showed that traits such as the ability to work as a ‘team’ and to build on definitions and methods of assessment for Impact through deliberation and ‘feedback’ were perceived along gendered lines. In this regard, women perceived themselves as valuable if they were ‘happy to listen to discussions’, and not ‘too dogmatic about their opinion’. Here, women were valued if they played a supportive, supplementary role in line with Bellas ( 1999 ), which was in clear distinction to men who contributed as creative thinkers and forgers of new ideas. As one panellist described;

A good panel member is an Irish female. A good panel member was someone who was happy to — someone who is happy to listen to discussions; to not be too dogmatic about their opinion, but can listen and learn, because impact is something we are all learning from scratch. Somebody who wasn’t too outspoken, was a team player. (Panel 3, Outputs and Impact, Female)

Likewise, another female evaluator reflected on the reasons for her inclusion as a panel member was due to her ‘generalist perspective’ as opposed to a perspective that is over prescribed. This was suggestive of how an overly specialist perspective would run counter to the reasons that she was included as a panellist which was, in her opinion, due to her value as an ethnic and gender ‘token’ to the panel;

‘ I think it’s also being able to provide some perspective, some general perspective. I’m quite a generalist actually, I’m not a specialist……So I’m very generalist. And I think they’re also well aware of the ethnic and gender composition of that and lots of reasons why I’m asked on panels. (Panel 1, Outputs and Impact, Female)

Women perceived their value on the panel as supportive, as someone who is prepared to work on the team, and listen to other views towards as a generalist, and constructionist, rather than as an enforced of dogmatic views and raw, hard notions of Impact that were represented through quantitative indicators only. As such, how the panel operated reflects general studies of how work can be organised along gender lines, as well as specific to workload and power in the academy. The similarity between the gendered associations towards conceptualising Impact from the researchers and evaluators, combined with how the panel organises its work along gendered lines, suggests how panel culture echoes the implicit tendencies within the wider research community. The implications of this tendency in relation to the evaluation of non-academic Impact is discussed below.

Discussion: an Impact a-gender?

This study shows how researchers and evaluators in two, independent data sets echoed a gendered orientation towards Impact, and how this implies an Impact a-gender. That gendered notions of Impact emerged as a significant theme from two independent data sets speaks to the importance of the issue. It also illustrates the need for policymakers and funding organisations to acknowledge its potential effects as part of their efforts towards embedding a more inclusive research culture around the generation and evaluation of research impact beyond academia.

Specifically, this paper has identified gendered language around the generation of, and evaluation of Impact by researchers in Australia and the UK, as well as by evaluators by the UK’s most recent Research Excellence Framework in 2014. For the UK and Australia, the prominence of Impact, as well as the policy borrowing between each country (Chubb, 2017 ) means that a reliable comparison of pre-evaluation perceptions of researchers and evaluators can be made. In both data sets presumptions of Impact as either ‘soft’ or ‘hard’ by both researchers and evaluators were found to be gendered. Whereas it is not surprising that panel culture reflects the dominant trends within the wider academic culture, this paper raises the question of how the implicit operation of gender bias surrounding notions of scientific productivity and its measurement, invade and therefore unduly influence the evaluation of those notions during peer-review processes. This negates the motivation behind a broad Impact definition and evaluation as inclusive since unconscious bias towards women can still operate if left unchecked and unmanaged.

Gendered notions of excellence were also related to the ability to be ‘competitive’, and that once Impact became a formalised, countable and therefore competitive criterion, it also become masculine where previously it existed as a feminised concept related to female academic-ness. As a feminised concept, Impact once referred to notions of excellence requiring communication such as public engagement, or stakeholder coordination—the ‘softer’ impacts. However, this association only remains ‘soft’ insofar as Impact remains unmeasurable, or more nuanced in definition. This is especially pertinent for the evaluation of societal impact where already conceived ideas of engagement and ‘ women’s work ’ influence how evaluators assess the feasibility of impact narratives for the purposes of its assessment. This paper also raises the question that notions of gender in relation to Impact persist irrespective of the identities assumed for the purposes of its evaluation (i.e., as a peer reviewer). This is not to say that academic culture in the UK and Australia, where Impact is increasingly being formalised into rewards systems, is not changing. More that there is a tendency in some evaluations for the burden of evidence to be applied differently to genders due to tensions surrounding what women are ‘good’ at doing: engagement, versus what ‘men’ are good at doing regarding Impact. In this scenario, quantitative indicators of big, high-level impacts are to be attributable to male traits, rather than female. This has already been noted in student evaluations of teaching (Kogan et al., 2010 ) and of academic leadership performance where the focus on the evaluation is on how others interpret performance based on already held gendered views about competence based on behaviours (Williams et al., 2014 ; Holt and Ellis, 1998 ). As such, when researchers transcend these gendered identities that are specific to societal impact, there is a danger of an Impact-a-gender bias arising in the assessment and forecasting of Impact. This paper extends this understanding and outlines how this may also be the case for assessments of societal impact.

By examining perceptions, as well as using an inductive analysis, this study was able to unearth unconsciously employed gendered notions that would not have been prominent or possible to pick up if we asked the interviewees about gender directly. This was particularly the case for the re-analysis of the post-evaluation interviews. However, future studies might consider incorporating a disciplinary-specific perspective as although the evaluators were from the medical/biomedical disciplines, researchers were from a range of disciplines. This would identify any discipline-specific risk towards an Impact a-gender. Nonetheless, further work that characterises the impact a-gender, as well as explores its wider implications for gender inequities within HE is currently underway.

How research evidence is labelled as excellent and therefore trustworthy, is heavily dictated by an evaluation process that is perceived as impartial and fair. However, if evaluations are compounded by gender bias, this confounds assessments of excellence with gendered expectation of non-academic impact. Consequently, gendered expectations of excellence for non-academic impact has the potential to: unconsciously dissuade women from pursuing more masculinised types of impact; act as a barrier to how female researchers mobilise their research evidence; as well as limit the recognition female researchers gain as excellent and therefore trustworthy sources of evidence.

The aim of this paper was not to criticise the panellists and researchers for expressing gendered perspectives, nor to present evidence about how researchers are unduly influenced by gender bias. The results shown do not support either of these views. However, the aim of this paper was to acknowledge how gender bias in research Impact generation can lead to a panel culture dominated by academics that translate the implicit and explicit biases within academia that influence its evaluation. This paper raises an important question regarding what we term the ‘Impact a-gender’, which outlines a mechanism in which gender bias feeds into the generation and evaluation of a research criterion, which is not traditionally associated with a hard, metrics-masculinised output from research. Along with other techniques used to combat unconscious bias in research evaluation, simply by identifying, and naming the issue, this paper intends to combat its ill effects through a community-wide discussions as a mechanism for developing tools to mitigate its wider effect if left unchecked or merely accepted as ‘acceptable’. In addition, it is suggested that government and funding organisations explicitly refer to the impact a-gender as part of their wider EDI (Equity, Diversity and Inclusion) agendas towards minimising the influence of unconscious bias in research impact and evaluation.

Data availability

Data is available upon request subject to ethical considerations such as consent so as not to compromise the individual privacy of our participants.

Change history

19 may 2020.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

For the purposes of this paper, when the text refers to non-academic, societal impact, or the term ‘Impact’ we are referring to the change and effect as defined by REF2014/2021 and the larger conceptualisation of impact that is generated through knowledge exchange and engagement. In this way, the paper refers to a broad conceptualisation of research impact that occurs beyond academia. This allows a distinction between Impact as central to this article’s contribution, as opposed to academic impact, and general word ‘impact’.

Impact scholars or those who are ‘good at impact’ are often equated with applied researchers.

One might interpret this as meaning ‘economic impact’.

This is described in the next section as ‘women’s work’ by one evaluator.

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Acknowledgements

This research was funded by the UK Economic and Social Research Council (ESRC) Future Research Leaders Programme (ES/K008897/2). We would also like to acknowledge their peers for offering their views on the paper in advance of publication and in doing so thank Dr. Richard Watermeyer, University of Bath, Professor Paul Wakeling, University of York and Dr. Gabrielle Samuel, Kings College London.

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Chubb, J., Derrick, G.E. The impact a-gender: gendered orientations towards research Impact and its evaluation. Palgrave Commun 6 , 72 (2020). https://doi.org/10.1057/s41599-020-0438-z

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Gender Bias in Information Systems Research: A Literature Review

11 Pages Posted: 21 Feb 2021

Silvia Masiero

University of Oslo

Aleksi Aaltonen

Stevens Institute of Technology - School of Business

Date Written: December 13, 2020

Gender bias is a systemic, unfair difference in the way men and women are treated in a particular domain. We conduct a thematic review of 82 papers out of 7,260 total papers found in the IS Basket of 8 journals that centre on themes related to gender, identifying extant domains of contribution and qualifying gaps in gender bias research. The papers fall into three broad categories that i) incorporate gender as a variable in empirical research, ii) study gender imbalances in the IT industry, or iii) discuss gender bias in the academic IS profession. Based on the review, we delineate an agenda for further work to investigate the role of gender in the IS academic space.

Keywords: Academic IS, Gender bias, Gender imbalance, Literature review

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Mitigating Gender Bias in Natural Language Processing: Literature Review

Tony Sun , Andrew Gaut , Shirlyn Tang , Yuxin Huang , Mai ElSherief , Jieyu Zhao , Diba Mirza , Elizabeth Belding , Kai-Wei Chang , William Yang Wang

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• Mitigating Gender Bias in Natural Language Processing: Literature Review (Sun et al., ACL 2019)
• Tony Sun, Andrew Gaut, Shirlyn Tang, Yuxin Huang, Mai ElSherief, Jieyu Zhao, Diba Mirza, Elizabeth Belding, Kai-Wei Chang, and William Yang Wang. 2019. Mitigating Gender Bias in Natural Language Processing: Literature Review . In Proceedings of the 57th Annual Meeting of the Association for Computational Linguistics , pages 1630–1640, Florence, Italy. Association for Computational Linguistics.

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Twenty years of gender equality research: A scoping review based on a new semantic indicator

Contributed equally to this work with: Paola Belingheri, Filippo Chiarello, Andrea Fronzetti Colladon, Paola Rovelli

Roles Conceptualization, Formal analysis, Funding acquisition, Visualization, Writing – original draft, Writing – review & editing

Affiliation Dipartimento di Ingegneria dell’Energia, dei Sistemi, del Territorio e delle Costruzioni, Università degli Studi di Pisa, Largo L. Lazzarino, Pisa, Italy

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Visualization, Writing – original draft, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Engineering, University of Perugia, Perugia, Italy, Department of Management, Kozminski University, Warsaw, Poland

Roles Conceptualization, Formal analysis, Funding acquisition, Writing – original draft, Writing – review & editing

Affiliation Faculty of Economics and Management, Centre for Family Business Management, Free University of Bozen-Bolzano, Bozen-Bolzano, Italy

• Paola Belingheri, 
• Filippo Chiarello, 
• Andrea Fronzetti Colladon, 
• Paola Rovelli

• Published: September 21, 2021
• https://doi.org/10.1371/journal.pone.0256474
• Reader Comments

9 Nov 2021: The PLOS ONE Staff (2021) Correction: Twenty years of gender equality research: A scoping review based on a new semantic indicator. PLOS ONE 16(11): e0259930. https://doi.org/10.1371/journal.pone.0259930 View correction

Gender equality is a major problem that places women at a disadvantage thereby stymieing economic growth and societal advancement. In the last two decades, extensive research has been conducted on gender related issues, studying both their antecedents and consequences. However, existing literature reviews fail to provide a comprehensive and clear picture of what has been studied so far, which could guide scholars in their future research. Our paper offers a scoping review of a large portion of the research that has been published over the last 22 years, on gender equality and related issues, with a specific focus on business and economics studies. Combining innovative methods drawn from both network analysis and text mining, we provide a synthesis of 15,465 scientific articles. We identify 27 main research topics, we measure their relevance from a semantic point of view and the relationships among them, highlighting the importance of each topic in the overall gender discourse. We find that prominent research topics mostly relate to women in the workforce–e.g., concerning compensation, role, education, decision-making and career progression. However, some of them are losing momentum, and some other research trends–for example related to female entrepreneurship, leadership and participation in the board of directors–are on the rise. Besides introducing a novel methodology to review broad literature streams, our paper offers a map of the main gender-research trends and presents the most popular and the emerging themes, as well as their intersections, outlining important avenues for future research.

Citation: Belingheri P, Chiarello F, Fronzetti Colladon A, Rovelli P (2021) Twenty years of gender equality research: A scoping review based on a new semantic indicator. PLoS ONE 16(9): e0256474. https://doi.org/10.1371/journal.pone.0256474

Editor: Elisa Ughetto, Politecnico di Torino, ITALY

Received: June 25, 2021; Accepted: August 6, 2021; Published: September 21, 2021

Copyright: © 2021 Belingheri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its supporting information files. The only exception is the text of the abstracts (over 15,000) that we have downloaded from Scopus. These abstracts can be retrieved from Scopus, but we do not have permission to redistribute them.

Funding: P.B and F.C.: Grant of the Department of Energy, Systems, Territory and Construction of the University of Pisa (DESTEC) for the project “Measuring Gender Bias with Semantic Analysis: The Development of an Assessment Tool and its Application in the European Space Industry. P.B., F.C., A.F.C., P.R.: Grant of the Italian Association of Management Engineering (AiIG), “Misure di sostegno ai soci giovani AiIG” 2020, for the project “Gender Equality Through Data Intelligence (GEDI)”. F.C.: EU project ASSETs+ Project (Alliance for Strategic Skills addressing Emerging Technologies in Defence) EAC/A03/2018 - Erasmus+ programme, Sector Skills Alliances, Lot 3: Sector Skills Alliance for implementing a new strategic approach (Blueprint) to sectoral cooperation on skills G.A. NUMBER: 612678-EPP-1-2019-1-IT-EPPKA2-SSA-B.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The persistent gender inequalities that currently exist across the developed and developing world are receiving increasing attention from economists, policymakers, and the general public [e.g., 1 – 3 ]. Economic studies have indicated that women’s education and entry into the workforce contributes to social and economic well-being [e.g., 4 , 5 ], while their exclusion from the labor market and from managerial positions has an impact on overall labor productivity and income per capita [ 6 , 7 ]. The United Nations selected gender equality, with an emphasis on female education, as part of the Millennium Development Goals [ 8 ], and gender equality at-large as one of the 17 Sustainable Development Goals (SDGs) to be achieved by 2030 [ 9 ]. These latter objectives involve not only developing nations, but rather all countries, to achieve economic, social and environmental well-being.

As is the case with many SDGs, gender equality is still far from being achieved and persists across education, access to opportunities, or presence in decision-making positions [ 7 , 10 , 11 ]. As we enter the last decade for the SDGs’ implementation, and while we are battling a global health pandemic, effective and efficient action becomes paramount to reach this ambitious goal.

Scholars have dedicated a massive effort towards understanding gender equality, its determinants, its consequences for women and society, and the appropriate actions and policies to advance women’s equality. Many topics have been covered, ranging from women’s education and human capital [ 12 , 13 ] and their role in society [e.g., 14 , 15 ], to their appointment in firms’ top ranked positions [e.g., 16 , 17 ] and performance implications [e.g., 18 , 19 ]. Despite some attempts, extant literature reviews provide a narrow view on these issues, restricted to specific topics–e.g., female students’ presence in STEM fields [ 20 ], educational gender inequality [ 5 ], the gender pay gap [ 21 ], the glass ceiling effect [ 22 ], leadership [ 23 ], entrepreneurship [ 24 ], women’s presence on the board of directors [ 25 , 26 ], diversity management [ 27 ], gender stereotypes in advertisement [ 28 ], or specific professions [ 29 ]. A comprehensive view on gender-related research, taking stock of key findings and under-studied topics is thus lacking.

Extant literature has also highlighted that gender issues, and their economic and social ramifications, are complex topics that involve a large number of possible antecedents and outcomes [ 7 ]. Indeed, gender equality actions are most effective when implemented in unison with other SDGs (e.g., with SDG 8, see [ 30 ]) in a synergetic perspective [ 10 ]. Many bodies of literature (e.g., business, economics, development studies, sociology and psychology) approach the problem of achieving gender equality from different perspectives–often addressing specific and narrow aspects. This sometimes leads to a lack of clarity about how different issues, circumstances, and solutions may be related in precipitating or mitigating gender inequality or its effects. As the number of papers grows at an increasing pace, this issue is exacerbated and there is a need to step back and survey the body of gender equality literature as a whole. There is also a need to examine synergies between different topics and approaches, as well as gaps in our understanding of how different problems and solutions work together. Considering the important topic of women’s economic and social empowerment, this paper aims to fill this gap by answering the following research question: what are the most relevant findings in the literature on gender equality and how do they relate to each other ?

To do so, we conduct a scoping review [ 31 ], providing a synthesis of 15,465 articles dealing with gender equity related issues published in the last twenty-two years, covering both the periods of the MDGs and the SDGs (i.e., 2000 to mid 2021) in all the journals indexed in the Academic Journal Guide’s 2018 ranking of business and economics journals. Given the huge amount of research conducted on the topic, we adopt an innovative methodology, which relies on social network analysis and text mining. These techniques are increasingly adopted when surveying large bodies of text. Recently, they were applied to perform analysis of online gender communication differences [ 32 ] and gender behaviors in online technology communities [ 33 ], to identify and classify sexual harassment instances in academia [ 34 ], and to evaluate the gender inclusivity of disaster management policies [ 35 ].

Applied to the title, abstracts and keywords of the articles in our sample, this methodology allows us to identify a set of 27 recurrent topics within which we automatically classify the papers. Introducing additional novelty, by means of the Semantic Brand Score (SBS) indicator [ 36 ] and the SBS BI app [ 37 ], we assess the importance of each topic in the overall gender equality discourse and its relationships with the other topics, as well as trends over time, with a more accurate description than that offered by traditional literature reviews relying solely on the number of papers presented in each topic.

This methodology, applied to gender equality research spanning the past twenty-two years, enables two key contributions. First, we extract the main message that each document is conveying and how this is connected to other themes in literature, providing a rich picture of the topics that are at the center of the discourse, as well as of the emerging topics. Second, by examining the semantic relationship between topics and how tightly their discourses are linked, we can identify the key relationships and connections between different topics. This semi-automatic methodology is also highly reproducible with minimum effort.

This literature review is organized as follows. In the next section, we present how we selected relevant papers and how we analyzed them through text mining and social network analysis. We then illustrate the importance of 27 selected research topics, measured by means of the SBS indicator. In the results section, we present an overview of the literature based on the SBS results–followed by an in-depth narrative analysis of the top 10 topics (i.e., those with the highest SBS) and their connections. Subsequently, we highlight a series of under-studied connections between the topics where there is potential for future research. Through this analysis, we build a map of the main gender-research trends in the last twenty-two years–presenting the most popular themes. We conclude by highlighting key areas on which research should focused in the future.

Our aim is to map a broad topic, gender equality research, that has been approached through a host of different angles and through different disciplines. Scoping reviews are the most appropriate as they provide the freedom to map different themes and identify literature gaps, thereby guiding the recommendation of new research agendas [ 38 ].

Several practical approaches have been proposed to identify and assess the underlying topics of a specific field using big data [ 39 – 41 ], but many of them fail without proper paper retrieval and text preprocessing. This is specifically true for a research field such as the gender-related one, which comprises the work of scholars from different backgrounds. In this section, we illustrate a novel approach for the analysis of scientific (gender-related) papers that relies on methods and tools of social network analysis and text mining. Our procedure has four main steps: (1) data collection, (2) text preprocessing, (3) keywords extraction and classification, and (4) evaluation of semantic importance and image.

Data collection

In this study, we analyze 22 years of literature on gender-related research. Following established practice for scoping reviews [ 42 ], our data collection consisted of two main steps, which we summarize here below.

Firstly, we retrieved from the Scopus database all the articles written in English that contained the term “gender” in their title, abstract or keywords and were published in a journal listed in the Academic Journal Guide 2018 ranking of the Chartered Association of Business Schools (CABS) ( https://charteredabs.org/wp-content/uploads/2018/03/AJG2018-Methodology.pdf ), considering the time period from Jan 2000 to May 2021. We used this information considering that abstracts, titles and keywords represent the most informative part of a paper, while using the full-text would increase the signal-to-noise ratio for information extraction. Indeed, these textual elements already demonstrated to be reliable sources of information for the task of domain lexicon extraction [ 43 , 44 ]. We chose Scopus as source of literature because of its popularity, its update rate, and because it offers an API to ease the querying process. Indeed, while it does not allow to retrieve the full text of scientific articles, the Scopus API offers access to titles, abstracts, citation information and metadata for all its indexed scholarly journals. Moreover, we decided to focus on the journals listed in the AJG 2018 ranking because we were interested in reviewing business and economics related gender studies only. The AJG is indeed widely used by universities and business schools as a reference point for journal and research rigor and quality. This first step, executed in June 2021, returned more than 55,000 papers.

In the second step–because a look at the papers showed very sparse results, many of which were not in line with the topic of this literature review (e.g., papers dealing with health care or medical issues, where the word gender indicates the gender of the patients)–we applied further inclusion criteria to make the sample more focused on the topic of this literature review (i.e., women’s gender equality issues). Specifically, we only retained those papers mentioning, in their title and/or abstract, both gender-related keywords (e.g., daughter, female, mother) and keywords referring to bias and equality issues (e.g., equality, bias, diversity, inclusion). After text pre-processing (see next section), keywords were first identified from a frequency-weighted list of words found in the titles, abstracts and keywords in the initial list of papers, extracted through text mining (following the same approach as [ 43 ]). They were selected by two of the co-authors independently, following respectively a bottom up and a top-down approach. The bottom-up approach consisted of examining the words found in the frequency-weighted list and classifying those related to gender and equality. The top-down approach consisted in searching in the word list for notable gender and equality-related words. Table 1 reports the sets of keywords we considered, together with some examples of words that were used to search for their presence in the dataset (a full list is provided in the S1 Text ). At end of this second step, we obtained a final sample of 15,465 relevant papers.

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https://doi.org/10.1371/journal.pone.0256474.t001

Text processing and keyword extraction

Text preprocessing aims at structuring text into a form that can be analyzed by statistical models. In the present section, we describe the preprocessing steps we applied to paper titles and abstracts, which, as explained below, partially follow a standard text preprocessing pipeline [ 45 ]. These activities have been performed using the R package udpipe [ 46 ].

The first step is n-gram extraction (i.e., a sequence of words from a given text sample) to identify which n-grams are important in the analysis, since domain-specific lexicons are often composed by bi-grams and tri-grams [ 47 ]. Multi-word extraction is usually implemented with statistics and linguistic rules, thus using the statistical properties of n-grams or machine learning approaches [ 48 ]. However, for the present paper, we used Scopus metadata in order to have a more effective and efficient n-grams collection approach [ 49 ]. We used the keywords of each paper in order to tag n-grams with their associated keywords automatically. Using this greedy approach, it was possible to collect all the keywords listed by the authors of the papers. From this list, we extracted only keywords composed by two, three and four words, we removed all the acronyms and rare keywords (i.e., appearing in less than 1% of papers), and we clustered keywords showing a high orthographic similarity–measured using a Levenshtein distance [ 50 ] lower than 2, considering these groups of keywords as representing same concepts, but expressed with different spelling. After tagging the n-grams in the abstracts, we followed a common data preparation pipeline that consists of the following steps: (i) tokenization, that splits the text into tokens (i.e., single words and previously tagged multi-words); (ii) removal of stop-words (i.e. those words that add little meaning to the text, usually being very common and short functional words–such as “and”, “or”, or “of”); (iii) parts-of-speech tagging, that is providing information concerning the morphological role of a word and its morphosyntactic context (e.g., if the token is a determiner, the next token is a noun or an adjective with very high confidence, [ 51 ]); and (iv) lemmatization, which consists in substituting each word with its dictionary form (or lemma). The output of the latter step allows grouping together the inflected forms of a word. For example, the verbs “am”, “are”, and “is” have the shared lemma “be”, or the nouns “cat” and “cats” both share the lemma “cat”. We preferred lemmatization over stemming [ 52 ] in order to obtain more interpretable results.

In addition, we identified a further set of keywords (with respect to those listed in the “keywords” field) by applying a series of automatic words unification and removal steps, as suggested in past research [ 53 , 54 ]. We removed: sparse terms (i.e., occurring in less than 0.1% of all documents), common terms (i.e., occurring in more than 10% of all documents) and retained only nouns and adjectives. It is relevant to notice that no document was lost due to these steps. We then used the TF-IDF function [ 55 ] to produce a new list of keywords. We additionally tested other approaches for the identification and clustering of keywords–such as TextRank [ 56 ] or Latent Dirichlet Allocation [ 57 ]–without obtaining more informative results.

Classification of research topics

To guide the literature analysis, two experts met regularly to examine the sample of collected papers and to identify the main topics and trends in gender research. Initially, they conducted brainstorming sessions on the topics they expected to find, due to their knowledge of the literature. This led to an initial list of topics. Subsequently, the experts worked independently, also supported by the keywords in paper titles and abstracts extracted with the procedure described above.

Considering all this information, each expert identified and clustered relevant keywords into topics. At the end of the process, the two assignments were compared and exhibited a 92% agreement. Another meeting was held to discuss discordant cases and reach a consensus. This resulted in a list of 27 topics, briefly introduced in Table 2 and subsequently detailed in the following sections.

https://doi.org/10.1371/journal.pone.0256474.t002

Evaluation of semantic importance

Working on the lemmatized corpus of the 15,465 papers included in our sample, we proceeded with the evaluation of semantic importance trends for each topic and with the analysis of their connections and prevalent textual associations. To this aim, we used the Semantic Brand Score indicator [ 36 ], calculated through the SBS BI webapp [ 37 ] that also produced a brand image report for each topic. For this study we relied on the computing resources of the ENEA/CRESCO infrastructure [ 58 ].

The Semantic Brand Score (SBS) is a measure of semantic importance that combines methods of social network analysis and text mining. It is usually applied for the analysis of (big) textual data to evaluate the importance of one or more brands, names, words, or sets of keywords [ 36 ]. Indeed, the concept of “brand” is intended in a flexible way and goes beyond products or commercial brands. In this study, we evaluate the SBS time-trends of the keywords defining the research topics discussed in the previous section. Semantic importance comprises the three dimensions of topic prevalence, diversity and connectivity. Prevalence measures how frequently a research topic is used in the discourse. The more a topic is mentioned by scientific articles, the more the research community will be aware of it, with possible increase of future studies; this construct is partly related to that of brand awareness [ 59 ]. This effect is even stronger, considering that we are analyzing the title, abstract and keywords of the papers, i.e. the parts that have the highest visibility. A very important characteristic of the SBS is that it considers the relationships among words in a text. Topic importance is not just a matter of how frequently a topic is mentioned, but also of the associations a topic has in the text. Specifically, texts are transformed into networks of co-occurring words, and relationships are studied through social network analysis [ 60 ]. This step is necessary to calculate the other two dimensions of our semantic importance indicator. Accordingly, a social network of words is generated for each time period considered in the analysis–i.e., a graph made of n nodes (words) and E edges weighted by co-occurrence frequency, with W being the set of edge weights. The keywords representing each topic were clustered into single nodes.

The construct of diversity relates to that of brand image [ 59 ], in the sense that it considers the richness and distinctiveness of textual (topic) associations. Considering the above-mentioned networks, we calculated diversity using the distinctiveness centrality metric–as in the formula presented by Fronzetti Colladon and Naldi [ 61 ].

Lastly, connectivity was measured as the weighted betweenness centrality [ 62 , 63 ] of each research topic node. We used the formula presented by Wasserman and Faust [ 60 ]. The dimension of connectivity represents the “brokerage power” of each research topic–i.e., how much it can serve as a bridge to connect other terms (and ultimately topics) in the discourse [ 36 ].

The SBS is the final composite indicator obtained by summing the standardized scores of prevalence, diversity and connectivity. Standardization was carried out considering all the words in the corpus, for each specific timeframe.

This methodology, applied to a large and heterogeneous body of text, enables to automatically identify two important sets of information that add value to the literature review. Firstly, the relevance of each topic in literature is measured through a composite indicator of semantic importance, rather than simply looking at word frequencies. This provides a much richer picture of the topics that are at the center of the discourse, as well as of the topics that are emerging in the literature. Secondly, it enables to examine the extent of the semantic relationship between topics, looking at how tightly their discourses are linked. In a field such as gender equality, where many topics are closely linked to each other and present overlaps in issues and solutions, this methodology offers a novel perspective with respect to traditional literature reviews. In addition, it ensures reproducibility over time and the possibility to semi-automatically update the analysis, as new papers become available.

Overview of main topics

In terms of descriptive textual statistics, our corpus is made of 15,465 text documents, consisting of a total of 2,685,893 lemmatized tokens (words) and 32,279 types. As a result, the type-token ratio is 1.2%. The number of hapaxes is 12,141, with a hapax-token ratio of 37.61%.

Fig 1 shows the list of 27 topics by decreasing SBS. The most researched topic is compensation , exceeding all others in prevalence, diversity, and connectivity. This means it is not only mentioned more often than other topics, but it is also connected to a greater number of other topics and is central to the discourse on gender equality. The next four topics are, in order of SBS, role , education , decision-making , and career progression . These topics, except for education , all concern women in the workforce. Between these first five topics and the following ones there is a clear drop in SBS scores. In particular, the topics that follow have a lower connectivity than the first five. They are hiring , performance , behavior , organization , and human capital . Again, except for behavior and human capital , the other three topics are purely related to women in the workforce. After another drop-off, the following topics deal prevalently with women in society. This trend highlights that research on gender in business journals has so far mainly paid attention to the conditions that women experience in business contexts, while also devoting some attention to women in society.

https://doi.org/10.1371/journal.pone.0256474.g001

Fig 2 shows the SBS time series of the top 10 topics. While there has been a general increase in the number of Scopus-indexed publications in the last decade, we notice that some SBS trends remain steady, or even decrease. In particular, we observe that the main topic of the last twenty-two years, compensation , is losing momentum. Since 2016, it has been surpassed by decision-making , education and role , which may indicate that literature is increasingly attempting to identify root causes of compensation inequalities. Moreover, in the last two years, the topics of hiring , performance , and organization are experiencing the largest importance increase.

https://doi.org/10.1371/journal.pone.0256474.g002

Fig 3 shows the SBS time trends of the remaining 17 topics (i.e., those not in the top 10). As we can see from the graph, there are some that maintain a steady trend–such as reputation , management , networks and governance , which also seem to have little importance. More relevant topics with average stationary trends (except for the last two years) are culture , family , and parenting . The feminine topic is among the most important here, and one of those that exhibit the larger variations over time (similarly to leadership ). On the other hand, the are some topics that, even if not among the most important, show increasing SBS trends; therefore, they could be considered as emerging topics and could become popular in the near future. These are entrepreneurship , leadership , board of directors , and sustainability . These emerging topics are also interesting to anticipate future trends in gender equality research that are conducive to overall equality in society.

https://doi.org/10.1371/journal.pone.0256474.g003

In addition to the SBS score of the different topics, the network of terms they are associated to enables to gauge the extent to which their images (textual associations) overlap or differ ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0256474.g004

There is a central cluster of topics with high similarity, which are all connected with women in the workforce. The cluster includes topics such as organization , decision-making , performance , hiring , human capital , education and compensation . In addition, the topic of well-being is found within this cluster, suggesting that women’s equality in the workforce is associated to well-being considerations. The emerging topics of entrepreneurship and leadership are also closely connected with each other, possibly implying that leadership is a much-researched quality in female entrepreneurship. Topics that are relatively more distant include personality , politics , feminine , empowerment , management , board of directors , reputation , governance , parenting , masculine and network .

The following sections describe the top 10 topics and their main associations in literature (see Table 3 ), while providing a brief overview of the emerging topics.

https://doi.org/10.1371/journal.pone.0256474.t003

Compensation.

The topic of compensation is related to the topics of role , hiring , education and career progression , however, also sees a very high association with the words gap and inequality . Indeed, a well-known debate in degrowth economics centers around whether and how to adequately compensate women for their childbearing, childrearing, caregiver and household work [e.g., 30 ].

Even in paid work, women continue being offered lower compensations than their male counterparts who have the same job or cover the same role [ 64 – 67 ]. This severe inequality has been widely studied by scholars over the last twenty-two years. Dealing with this topic, some specific roles have been addressed. Specifically, research highlighted differences in compensation between female and male CEOs [e.g., 68 ], top executives [e.g., 69 ], and boards’ directors [e.g., 70 ]. Scholars investigated the determinants of these gaps, such as the gender composition of the board [e.g., 71 – 73 ] or women’s individual characteristics [e.g., 71 , 74 ].

Among these individual characteristics, education plays a relevant role [ 75 ]. Education is indeed presented as the solution for women, not only to achieve top executive roles, but also to reduce wage inequality [e.g., 76 , 77 ]. Past research has highlighted education influences on gender wage gaps, specifically referring to gender differences in skills [e.g., 78 ], college majors [e.g., 79 ], and college selectivity [e.g., 80 ].

Finally, the wage gap issue is strictly interrelated with hiring –e.g., looking at whether being a mother affects hiring and compensation [e.g., 65 , 81 ] or relating compensation to unemployment [e.g., 82 ]–and career progression –for instance looking at meritocracy [ 83 , 84 ] or the characteristics of the boss for whom women work [e.g., 85 ].

The roles covered by women have been deeply investigated. Scholars have focused on the role of women in their families and the society as a whole [e.g., 14 , 15 ], and, more widely, in business contexts [e.g., 18 , 81 ]. Indeed, despite still lagging behind their male counterparts [e.g., 86 , 87 ], in the last decade there has been an increase in top ranked positions achieved by women [e.g., 88 , 89 ]. Following this phenomenon, scholars have posed greater attention towards the presence of women in the board of directors [e.g., 16 , 18 , 90 , 91 ], given the increasing pressure to appoint female directors that firms, especially listed ones, have experienced. Other scholars have focused on the presence of women covering the role of CEO [e.g., 17 , 92 ] or being part of the top management team [e.g., 93 ]. Irrespectively of the level of analysis, all these studies tried to uncover the antecedents of women’s presence among top managers [e.g., 92 , 94 ] and the consequences of having a them involved in the firm’s decision-making –e.g., on performance [e.g., 19 , 95 , 96 ], risk [e.g., 97 , 98 ], and corporate social responsibility [e.g., 99 , 100 ].

Besides studying the difficulties and discriminations faced by women in getting a job [ 81 , 101 ], and, more specifically in the hiring , appointment, or career progression to these apical roles [e.g., 70 , 83 ], the majority of research of women’s roles dealt with compensation issues. Specifically, scholars highlight the pay-gap that still exists between women and men, both in general [e.g., 64 , 65 ], as well as referring to boards’ directors [e.g., 70 , 102 ], CEOs and executives [e.g., 69 , 103 , 104 ].

Finally, other scholars focused on the behavior of women when dealing with business. In this sense, particular attention has been paid to leadership and entrepreneurial behaviors. The former quite overlaps with dealing with the roles mentioned above, but also includes aspects such as leaders being stereotyped as masculine [e.g., 105 ], the need for greater exposure to female leaders to reduce biases [e.g., 106 ], or female leaders acting as queen bees [e.g., 107 ]. Regarding entrepreneurship , scholars mainly investigated women’s entrepreneurial entry [e.g., 108 , 109 ], differences between female and male entrepreneurs in the evaluations and funding received from investors [e.g., 110 , 111 ], and their performance gap [e.g., 112 , 113 ].

Education has long been recognized as key to social advancement and economic stability [ 114 ], for job progression and also a barrier to gender equality, especially in STEM-related fields. Research on education and gender equality is mostly linked with the topics of compensation , human capital , career progression , hiring , parenting and decision-making .

Education contributes to a higher human capital [ 115 ] and constitutes an investment on the part of women towards their future. In this context, literature points to the gender gap in educational attainment, and the consequences for women from a social, economic, personal and professional standpoint. Women are found to have less access to formal education and information, especially in emerging countries, which in turn may cause them to lose social and economic opportunities [e.g., 12 , 116 – 119 ]. Education in local and rural communities is also paramount to communicate the benefits of female empowerment , contributing to overall societal well-being [e.g., 120 ].

Once women access education, the image they have of the world and their place in society (i.e., habitus) affects their education performance [ 13 ] and is passed on to their children. These situations reinforce gender stereotypes, which become self-fulfilling prophecies that may negatively affect female students’ performance by lowering their confidence and heightening their anxiety [ 121 , 122 ]. Besides formal education, also the information that women are exposed to on a daily basis contributes to their human capital . Digital inequalities, for instance, stems from men spending more time online and acquiring higher digital skills than women [ 123 ].

Education is also a factor that should boost employability of candidates and thus hiring , career progression and compensation , however the relationship between these factors is not straightforward [ 115 ]. First, educational choices ( decision-making ) are influenced by variables such as self-efficacy and the presence of barriers, irrespectively of the career opportunities they offer, especially in STEM [ 124 ]. This brings additional difficulties to women’s enrollment and persistence in scientific and technical fields of study due to stereotypes and biases [ 125 , 126 ]. Moreover, access to education does not automatically translate into job opportunities for women and minority groups [ 127 , 128 ] or into female access to managerial positions [ 129 ].

Finally, parenting is reported as an antecedent of education [e.g., 130 ], with much of the literature focusing on the role of parents’ education on the opportunities afforded to children to enroll in education [ 131 – 134 ] and the role of parenting in their offspring’s perception of study fields and attitudes towards learning [ 135 – 138 ]. Parental education is also a predictor of the other related topics, namely human capital and compensation [ 139 ].

Decision-making.

This literature mainly points to the fact that women are thought to make decisions differently than men. Women have indeed different priorities, such as they care more about people’s well-being, working with people or helping others, rather than maximizing their personal (or their firm’s) gain [ 140 ]. In other words, women typically present more communal than agentic behaviors, which are instead more frequent among men [ 141 ]. These different attitude, behavior and preferences in turn affect the decisions they make [e.g., 142 ] and the decision-making of the firm in which they work [e.g., 143 ].

At the individual level, gender affects, for instance, career aspirations [e.g., 144 ] and choices [e.g., 142 , 145 ], or the decision of creating a venture [e.g., 108 , 109 , 146 ]. Moreover, in everyday life, women and men make different decisions regarding partners [e.g., 147 ], childcare [e.g., 148 ], education [e.g., 149 ], attention to the environment [e.g., 150 ] and politics [e.g., 151 ].

At the firm level, scholars highlighted, for example, how the presence of women in the board affects corporate decisions [e.g., 152 , 153 ], that female CEOs are more conservative in accounting decisions [e.g., 154 ], or that female CFOs tend to make more conservative decisions regarding the firm’s financial reporting [e.g., 155 ]. Nevertheless, firm level research also investigated decisions that, influenced by gender bias, affect women, such as those pertaining hiring [e.g., 156 , 157 ], compensation [e.g., 73 , 158 ], or the empowerment of women once appointed [ 159 ].

Career progression.

Once women have entered the workforce, the key aspect to achieve gender equality becomes career progression , including efforts toward overcoming the glass ceiling. Indeed, according to the SBS analysis, career progression is highly related to words such as work, social issues and equality. The topic with which it has the highest semantic overlap is role , followed by decision-making , hiring , education , compensation , leadership , human capital , and family .

Career progression implies an advancement in the hierarchical ladder of the firm, assigning managerial roles to women. Coherently, much of the literature has focused on identifying rationales for a greater female participation in the top management team and board of directors [e.g., 95 ] as well as the best criteria to ensure that the decision-makers promote the most valuable employees irrespectively of their individual characteristics, such as gender [e.g., 84 ]. The link between career progression , role and compensation is often provided in practice by performance appraisal exercises, frequently rooted in a culture of meritocracy that guides bonuses, salary increases and promotions. However, performance appraisals can actually mask gender-biased decisions where women are held to higher standards than their male colleagues [e.g., 83 , 84 , 95 , 160 , 161 ]. Women often have less opportunities to gain leadership experience and are less visible than their male colleagues, which constitute barriers to career advancement [e.g., 162 ]. Therefore, transparency and accountability, together with procedures that discourage discretionary choices, are paramount to achieve a fair career progression [e.g., 84 ], together with the relaxation of strict job boundaries in favor of cross-functional and self-directed tasks [e.g., 163 ].

In addition, a series of stereotypes about the type of leadership characteristics that are required for top management positions, which fit better with typical male and agentic attributes, are another key barrier to career advancement for women [e.g., 92 , 160 ].

Hiring is the entrance gateway for women into the workforce. Therefore, it is related to other workforce topics such as compensation , role , career progression , decision-making , human capital , performance , organization and education .

A first stream of literature focuses on the process leading up to candidates’ job applications, demonstrating that bias exists before positions are even opened, and it is perpetuated both by men and women through networking and gatekeeping practices [e.g., 164 , 165 ].

The hiring process itself is also subject to biases [ 166 ], for example gender-congruity bias that leads to men being preferred candidates in male-dominated sectors [e.g., 167 ], women being hired in positions with higher risk of failure [e.g., 168 ] and limited transparency and accountability afforded by written processes and procedures [e.g., 164 ] that all contribute to ascriptive inequality. In addition, providing incentives for evaluators to hire women may actually work to this end; however, this is not the case when supporting female candidates endangers higher-ranking male ones [ 169 ].

Another interesting perspective, instead, looks at top management teams’ composition and the effects on hiring practices, indicating that firms with more women in top management are less likely to lay off staff [e.g., 152 ].

Performance.

Several scholars posed their attention towards women’s performance, its consequences [e.g., 170 , 171 ] and the implications of having women in decision-making positions [e.g., 18 , 19 ].

At the individual level, research focused on differences in educational and academic performance between women and men, especially referring to the gender gap in STEM fields [e.g., 171 ]. The presence of stereotype threats–that is the expectation that the members of a social group (e.g., women) “must deal with the possibility of being judged or treated stereotypically, or of doing something that would confirm the stereotype” [ 172 ]–affects women’s interested in STEM [e.g., 173 ], as well as their cognitive ability tests, penalizing them [e.g., 174 ]. A stronger gender identification enhances this gap [e.g., 175 ], whereas mentoring and role models can be used as solutions to this problem [e.g., 121 ]. Despite the negative effect of stereotype threats on girls’ performance [ 176 ], female and male students perform equally in mathematics and related subjects [e.g., 177 ]. Moreover, while individuals’ performance at school and university generally affects their achievements and the field in which they end up working, evidence reveals that performance in math or other scientific subjects does not explain why fewer women enter STEM working fields; rather this gap depends on other aspects, such as culture, past working experiences, or self-efficacy [e.g., 170 ]. Finally, scholars have highlighted the penalization that women face for their positive performance, for instance when they succeed in traditionally male areas [e.g., 178 ]. This penalization is explained by the violation of gender-stereotypic prescriptions [e.g., 179 , 180 ], that is having women well performing in agentic areas, which are typical associated to men. Performance penalization can thus be overcome by clearly conveying communal characteristics and behaviors [ 178 ].

Evidence has been provided on how the involvement of women in boards of directors and decision-making positions affects firms’ performance. Nevertheless, results are mixed, with some studies showing positive effects on financial [ 19 , 181 , 182 ] and corporate social performance [ 99 , 182 , 183 ]. Other studies maintain a negative association [e.g., 18 ], and other again mixed [e.g., 184 ] or non-significant association [e.g., 185 ]. Also with respect to the presence of a female CEO, mixed results emerged so far, with some researches demonstrating a positive effect on firm’s performance [e.g., 96 , 186 ], while other obtaining only a limited evidence of this relationship [e.g., 103 ] or a negative one [e.g., 187 ].

Finally, some studies have investigated whether and how women’s performance affects their hiring [e.g., 101 ] and career progression [e.g., 83 , 160 ]. For instance, academic performance leads to different returns in hiring for women and men. Specifically, high-achieving men are called back significantly more often than high-achieving women, which are penalized when they have a major in mathematics; this result depends on employers’ gendered standards for applicants [e.g., 101 ]. Once appointed, performance ratings are more strongly related to promotions for women than men, and promoted women typically show higher past performance ratings than those of promoted men. This suggesting that women are subject to stricter standards for promotion [e.g., 160 ].

Behavioral aspects related to gender follow two main streams of literature. The first examines female personality and behavior in the workplace, and their alignment with cultural expectations or stereotypes [e.g., 188 ] as well as their impacts on equality. There is a common bias that depicts women as less agentic than males. Certain characteristics, such as those more congruent with male behaviors–e.g., self-promotion [e.g., 189 ], negotiation skills [e.g., 190 ] and general agentic behavior [e.g., 191 ]–, are less accepted in women. However, characteristics such as individualism in women have been found to promote greater gender equality in society [ 192 ]. In addition, behaviors such as display of emotions [e.g., 193 ], which are stereotypically female, work against women’s acceptance in the workplace, requiring women to carefully moderate their behavior to avoid exclusion. A counter-intuitive result is that women and minorities, which are more marginalized in the workplace, tend to be better problem-solvers in innovation competitions due to their different knowledge bases [ 194 ].

The other side of the coin is examined in a parallel literature stream on behavior towards women in the workplace. As a result of biases, prejudices and stereotypes, women may experience adverse behavior from their colleagues, such as incivility and harassment, which undermine their well-being [e.g., 195 , 196 ]. Biases that go beyond gender, such as for overweight people, are also more strongly applied to women [ 197 ].

Organization.

The role of women and gender bias in organizations has been studied from different perspectives, which mirror those presented in detail in the following sections. Specifically, most research highlighted the stereotypical view of leaders [e.g., 105 ] and the roles played by women within firms, for instance referring to presence in the board of directors [e.g., 18 , 90 , 91 ], appointment as CEOs [e.g., 16 ], or top executives [e.g., 93 ].

Scholars have investigated antecedents and consequences of the presence of women in these apical roles. On the one side they looked at hiring and career progression [e.g., 83 , 92 , 160 , 168 , 198 ], finding women typically disadvantaged with respect to their male counterparts. On the other side, they studied women’s leadership styles and influence on the firm’s decision-making [e.g., 152 , 154 , 155 , 199 ], with implications for performance [e.g., 18 , 19 , 96 ].

Human capital.

Human capital is a transverse topic that touches upon many different aspects of female gender equality. As such, it has the most associations with other topics, starting with education as mentioned above, with career-related topics such as role , decision-making , hiring , career progression , performance , compensation , leadership and organization . Another topic with which there is a close connection is behavior . In general, human capital is approached both from the education standpoint but also from the perspective of social capital.

The behavioral aspect in human capital comprises research related to gender differences for example in cultural and religious beliefs that influence women’s attitudes and perceptions towards STEM subjects [ 142 , 200 – 202 ], towards employment [ 203 ] or towards environmental issues [ 150 , 204 ]. These cultural differences also emerge in the context of globalization which may accelerate gender equality in the workforce [ 205 , 206 ]. Gender differences also appear in behaviors such as motivation [ 207 ], and in negotiation [ 190 ], and have repercussions on women’s decision-making related to their careers. The so-called gender equality paradox sees women in countries with lower gender equality more likely to pursue studies and careers in STEM fields, whereas the gap in STEM enrollment widens as countries achieve greater equality in society [ 171 ].

Career progression is modeled by literature as a choice-process where personal preferences, culture and decision-making affect the chosen path and the outcomes. Some literature highlights how women tend to self-select into different professions than men, often due to stereotypes rather than actual ability to perform in these professions [ 142 , 144 ]. These stereotypes also affect the perceptions of female performance or the amount of human capital required to equal male performance [ 110 , 193 , 208 ], particularly for mothers [ 81 ]. It is therefore often assumed that women are better suited to less visible and less leadership -oriented roles [ 209 ]. Women also express differing preferences towards work-family balance, which affect whether and how they pursue human capital gains [ 210 ], and ultimately their career progression and salary .

On the other hand, men are often unaware of gendered processes and behaviors that they carry forward in their interactions and decision-making [ 211 , 212 ]. Therefore, initiatives aimed at increasing managers’ human capital –by raising awareness of gender disparities in their organizations and engaging them in diversity promotion–are essential steps to counter gender bias and segregation [ 213 ].

Emerging topics: Leadership and entrepreneurship

Among the emerging topics, the most pervasive one is women reaching leadership positions in the workforce and in society. This is still a rare occurrence for two main types of factors, on the one hand, bias and discrimination make it harder for women to access leadership positions [e.g., 214 – 216 ], on the other hand, the competitive nature and high pressure associated with leadership positions, coupled with the lack of women currently represented, reduce women’s desire to achieve them [e.g., 209 , 217 ]. Women are more effective leaders when they have access to education, resources and a diverse environment with representation [e.g., 218 , 219 ].

One sector where there is potential for women to carve out a leadership role is entrepreneurship . Although at the start of the millennium the discourse on entrepreneurship was found to be “discriminatory, gender-biased, ethnocentrically determined and ideologically controlled” [ 220 ], an increasing body of literature is studying how to stimulate female entrepreneurship as an alternative pathway to wealth, leadership and empowerment [e.g., 221 ]. Many barriers exist for women to access entrepreneurship, including the institutional and legal environment, social and cultural factors, access to knowledge and resources, and individual behavior [e.g., 222 , 223 ]. Education has been found to raise women’s entrepreneurial intentions [e.g., 224 ], although this effect is smaller than for men [e.g., 109 ]. In addition, increasing self-efficacy and risk-taking behavior constitute important success factors [e.g., 225 ].

Finally, the topic of sustainability is worth mentioning, as it is the primary objective of the SDGs and is closely associated with societal well-being. As society grapples with the effects of climate change and increasing depletion of natural resources, a narrative has emerged on women and their greater link to the environment [ 226 ]. Studies in developed countries have found some support for women leaders’ attention to sustainability issues in firms [e.g., 227 – 229 ], and smaller resource consumption by women [ 230 ]. At the same time, women will likely be more affected by the consequences of climate change [e.g., 230 ] but often lack the decision-making power to influence local decision-making on resource management and environmental policies [e.g., 231 ].

Research gaps and conclusions

Research on gender equality has advanced rapidly in the past decades, with a steady increase in publications, both in mainstream topics related to women in education and the workforce, and in emerging topics. Through a novel approach combining methods of text mining and social network analysis, we examined a comprehensive body of literature comprising 15,465 papers published between 2000 and mid 2021 on topics related to gender equality. We identified a set of 27 topics addressed by the literature and examined their connections.

At the highest level of abstraction, it is worth noting that papers abound on the identification of issues related to gender inequalities and imbalances in the workforce and in society. Literature has thoroughly examined the (unconscious) biases, barriers, stereotypes, and discriminatory behaviors that women are facing as a result of their gender. Instead, there are much fewer papers that discuss or demonstrate effective solutions to overcome gender bias [e.g., 121 , 143 , 145 , 163 , 194 , 213 , 232 ]. This is partly due to the relative ease in studying the status quo, as opposed to studying changes in the status quo. However, we observed a shift in the more recent years towards solution seeking in this domain, which we strongly encourage future researchers to focus on. In the future, we may focus on collecting and mapping pro-active contributions to gender studies, using additional Natural Language Processing techniques, able to measure the sentiment of scientific papers [ 43 ].

All of the mainstream topics identified in our literature review are closely related, and there is a wealth of insights looking at the intersection between issues such as education and career progression or human capital and role . However, emerging topics are worthy of being furtherly explored. It would be interesting to see more work on the topic of female entrepreneurship , exploring aspects such as education , personality , governance , management and leadership . For instance, how can education support female entrepreneurship? How can self-efficacy and risk-taking behaviors be taught or enhanced? What are the differences in managerial and governance styles of female entrepreneurs? Which personality traits are associated with successful entrepreneurs? Which traits are preferred by venture capitalists and funding bodies?

The emerging topic of sustainability also deserves further attention, as our society struggles with climate change and its consequences. It would be interesting to see more research on the intersection between sustainability and entrepreneurship , looking at how female entrepreneurs are tackling sustainability issues, examining both their business models and their company governance . In addition, scholars are suggested to dig deeper into the relationship between family values and behaviors.

Moreover, it would be relevant to understand how women’s networks (social capital), or the composition and structure of social networks involving both women and men, enable them to increase their remuneration and reach top corporate positions, participate in key decision-making bodies, and have a voice in communities. Furthermore, the achievement of gender equality might significantly change firm networks and ecosystems, with important implications for their performance and survival.

Similarly, research at the nexus of (corporate) governance , career progression , compensation and female empowerment could yield useful insights–for example discussing how enterprises, institutions and countries are managed and the impact for women and other minorities. Are there specific governance structures that favor diversity and inclusion?

Lastly, we foresee an emerging stream of research pertaining how the spread of the COVID-19 pandemic challenged women, especially in the workforce, by making gender biases more evident.

For our analysis, we considered a set of 15,465 articles downloaded from the Scopus database (which is the largest abstract and citation database of peer-reviewed literature). As we were interested in reviewing business and economics related gender studies, we only considered those papers published in journals listed in the Academic Journal Guide (AJG) 2018 ranking of the Chartered Association of Business Schools (CABS). All the journals listed in this ranking are also indexed by Scopus. Therefore, looking at a single database (i.e., Scopus) should not be considered a limitation of our study. However, future research could consider different databases and inclusion criteria.

With our literature review, we offer researchers a comprehensive map of major gender-related research trends over the past twenty-two years. This can serve as a lens to look to the future, contributing to the achievement of SDG5. Researchers may use our study as a starting point to identify key themes addressed in the literature. In addition, our methodological approach–based on the use of the Semantic Brand Score and its webapp–could support scholars interested in reviewing other areas of research.

Supporting information

S1 text. keywords used for paper selection..

https://doi.org/10.1371/journal.pone.0256474.s001

Acknowledgments

The computing resources and the related technical support used for this work have been provided by CRESCO/ENEAGRID High Performance Computing infrastructure and its staff. CRESCO/ENEAGRID High Performance Computing infrastructure is funded by ENEA, the Italian National Agency for New Technologies, Energy and Sustainable Economic Development and by Italian and European research programmes (see http://www.cresco.enea.it/english for information).

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"Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain

Affiliations.

• 1 Epidemiology and Social Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg SE-405 30, Sweden.
• 2 Centre for Healthcare Improvment, Division of Service Management and Logistics, Department of Technology Management and Economics, Chalmers University of Technology, Göteborg SE-412 96, Sweden.
• PMID: 29682130
• PMCID: PMC5845507
• DOI: 10.1155/2018/6358624

Background: Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.

Methods: A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.

Results: The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.

Conclusions: Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

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• v.2018; 2018

“Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain

Anke samulowitz.

1 Epidemiology and Social Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg SE-405 30, Sweden

2 Centre for Healthcare Improvment, Division of Service Management and Logistics, Department of Technology Management and Economics, Chalmers University of Technology, Göteborg SE-412 96, Sweden

Erik Eriksson

Gunnel hensing.

Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.

A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.

The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.

Conclusions

Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

1. Introduction

Pain is a symptom in a wide range of medical conditions and can have a significant impact on a person's quality of life, general functioning, and employment status [ 1 ]. Women dominate most diagnoses related to chronic pain [ 1 – 4 ], and research has consistently shown differences between the sexes, like the perception, description and expression of pain, the use of coping strategies, and the benefit of different treatments [ 2 , 5 – 7 ]. There are convincing findings that biological differences contribute to the observed sex differences [ 2 , 3 , 7 ]. Genetic factors, as well as hormonal factors, act as sex-specific pain mediators [ 2 , 3 , 5 , 8 – 10 ]. Studies have found that women's pain responses are affected by menstrual cycle, pregnancy, and oral conceptive use [ 2 , 3 , 5 , 8 – 10 ], which confirms that hormones are related to pain response. In addition, the response to opioid receptor antagonists may generate a difference between men's and women's experiences of pain [ 2 , 3 , 5 , 8 – 10 ]. However, more research is needed to fully understand the underlying biological mechanisms [ 2 , 3 , 5 , 8 – 10 ].

Even psychosocial factors have been uplifted as explanations for sex differences. Pain is, by definition, always subjective [ 11 ]. Pain scales, widely used to assess a person's pain in research and clinical practice [ 2 , 12 , 13 ], measure pain report, which, in turn, can be influenced by social factors, like gender. From an early age, boys and girls are socialized along gender norms for how to respond to pain. Myers et al. suggested that boys and men are taught to be tough, tolerate pain, and sustain painful experiences, while girls and women are socialized to be sensitive, careful, and to verbalize discomfort [ 14 ]. Sex-related expectations about pain perception influence pain responses [ 7 ]. In experimental settings, participants who scored high on masculinity showed higher pain tolerance. Participants who scored high on femininity showed higher pain sensitivity [ 15 ]. In a cold pressure task, women showed lower pain threshold and tolerance compared to men. When the condition was changed so that men and women were given the same tolerance expectations prior to the task (“the typical man/woman lasts 30 seconds”), there were no longer any differences between men and women regarding pain threshold, tolerance, and pain ratings [ 16 ].

Consequently, gender role expectations influence perception and report of pain. However, it has to be further examined to what degree sex and gender role expectations, respectively, and together influence pain ratings [ 17 ].

Neither sex nor gender alone can account for observed pain differences between men and women [ 2 , 5 , 6 , 17 ]. The need to include both sex and gender in pain research, and to separate these concepts correctly, has been argued critically [ 2 , 18 , 19 ]. However, it is difficult to dissociate sex and gender—biological, psychological and social differences between men and women with respect to pain—as these differences are interrelated [ 2 , 3 , 10 ].

Given the still unexplained differences between men and women in pain, it is relevant to look for other explanatory factors. Of interest for such a scope is potential influence of gender norms. Gender norms are culture-based and express expectations about men's and women's interests, behaviors, and choices in life [ 19 , 20 ]. Gender norms also express male power dominance where men and women are regarded as inherently different (separation), and male values are usually seen as more favorable than female attributes (dominance) [ 20 ]. Gender norms are reflected in health care. They can be held by patients, researchers, and clinicians and can lead to gender bias, medically unmotivated differences in the treatment of men and women [ 3 , 18 ]. In recent years, a variety of examples have been presented in which men and women have been treated differently for the same diseases, medically unmotivated, across a wide range of medical fields including psoriasis [ 21 ], neck pain [ 22 ], heart disease [ 23 ], and polypharmacy [ 24 ]. Pain, especially chronic pain, is a field in medicine and medical care that has been pointed out to be affected by gender bias [ 6 , 10 , 13 ]. However, there is a lack of knowledge about how gender bias manifest in pain treatment, especially in clinical practice and in the patient-provider encounter [ 2 , 3 , 25 , 26 ].

Chronic pain is common in all western societies [ 1 , 4 ], challenging both health care and working life. In a large population-based European telephone survey, 19 percent of the participants reported moderate to severe pain, defined as lasting 6 months or more and experienced several times during the week prior to the interview [ 1 ]. The results showed that chronic pain had a pervasive impact on activities of daily life, employment status, and emotional status [ 1 ]. Patients with chronic pain occupy 20–40 percent of all consultations in Swedish primary health care [ 27 ]. Another Swedish study calculated that the mean total cost (direct and societal cost) per patient with chronic pain, per year, was 6400 EUR [ 28 ]. Given the amount of people suffering from pain and the dominance of women with pain diagnoses, it should be of great value to review, analyze, and compile research on gender norms and gender bias in pain treatment, as a tool to increase health-care providers' consciousness about potential gender bias and thereby improve equity in health and the treatment of all pain patients. This review will contribute with knowledge from different scientific fields, and with a theory-guided categorization and analysis of the literature reviewed.

2. Theoretical Framework

As evidence-based medicine is a cornerstone in health care, professionals need to apply research results in their daily work [ 29 ]; and their medical decisions should be based on current best evidence [ 29 ]. However, there are pitfalls, even in current research, like the inadequate generalization of results to a greater population than studied. One example is research on men as a basis for treatment of both men and women. Gender-blindness, the “nonawareness of the fact that a great deal of knowledge is based on research performed in men” [ 30 ], has been identified as an obstacle for gender equity in health care. As late as in 2007, the Sex, Gender and Pain Special Interest Group of the International Association for the Study of Pain stated that females are underrepresented in animal and human studies and recommended that “both constructs (sex and gender) should be examined when possible in order to understand their relative contribution to differences in pain between men and women” (p. 27) [ 3 ]. Without sufficient consciousness about sex and gender-biased research, it has been common to neutralize both patients and professionals [ 31 ]. Diagnostics and treatments evolved on men were announced as diagnostics and treatments for patients, including men and women. Despite regulations dictating the inclusion of men and women in medical research, gender-blind attitudes can still be observed. Hølge–Hazelton and Malterud suggested, “A notion of gender neutrality is still alive in the medical culture, suggesting that gender issues are not relevant within this field” (p. 139) [ 31 ]. Gender-blindness can lead to women's needs being overlooked, as seen in coronary heart diseases [ 23 ], but can also lead to that men's needs are failed to notice, as seen in under-diagnosed depression in men [ 32 ].

The term hegemonic masculinity describes a pattern of masculine attributes, behaviors, and practices which are constructed as the prevailing and idealized norm and against which both men and women are evaluated [ 33 ]. Hegemonic masculinity is practiced individually and structurally, is built on consensus within a social environment, and can change over time [ 33 ]. It expresses a dominance of men over women and over other men that do not live up to idealized norms like physical strength, technical competence, autonomy, and self-reliance [ 33 ]. Regarding pain patients, masculine attributes like strength, endurance, and stoicism are valued higher than feminine attributes like sensitivity and to express discomfort [ 6 ]. Even if the concept of hegemonic masculinity has been further developed and its complexity has been underlined [ 33 ], it is still used to explain dominant relations between men and women but also among men, in general [ 33 ] and in health care [ 6 ].

Even the concept of andronormativity has been discussed and applied to health care. Andronormativity implies that masculinity and male values are regarded as normal in medicine to such an extent that femininity and female values are invisible and need to be highlighted in order to be recognized [ 31 ]. Andronormativity has consequences for which conditions are prioritized or downprioritized in research and health care and may be reflected in status hierarchies of diagnoses [ 34 ]. Album and Westin showed that women-dominated conditions like fibromyalgia and anxiety neurosis were rated as the least prestigious among 38 diseases [ 35 ]. Andronormativity has also consequences for how male behavior is seen as normal in conditions that affect both men and women. Men and women with angina symptoms often express different pain locations [ 36 ]. Even though angina is common in both men and women, it has been shown that women's pain has been referred to as atypical, which in this context means not like men's pain, positioning men's pain as the norm [ 36 ].

The purpose of this study is to review literature from medical, behavioral, and social sciences on (i) gendered norms about men and women with pain, (ii) gendered norms about how men and women with pain cope with their daily life, and (iii) gender bias in the treatment of pain including both the patient-provider encounter and professional treatment decisions. However, the aim of this study is not to prove if gendered norms in health care exist—which earlier research already has shown [ 2 , 3 , 13 ]—but to collect and analyze gendered norms and gender bias as described in pain literature and deepen the knowledge about them. The second purpose is to analyze the findings in relation to concepts of hegemonic masculinity and andronormativity in the health care, as a general driving force of gender constructions in Western societies.

In this review, sex is defined as a biological construct, in terms of differences between men and women concerning anatomy, physiology, genes, and hormones. Gender is defined as “a social construct regarding culture-bound conventions, roles, and behaviors for, as well as relations between and among, women and men and boys and girls” (p 653) [ 18 ]. Gender norms concern behaviors which are generally considered to be appropriate, desirable, and “normal” for men or for women [ 19 ]. In this review, we also use the term gendered norms. In different situations and areas in daily life, different reactions and behaviors of men and women are expected. Thus, norms about leisure activities, reactions to life events, social relations and so on are gendered and go along with different expectations on men and women, which in turn risks to consolidate the dichotomous construction of gender.

This study was designed as a theory-guided review, with the purpose to collect knowledge generated through diverse methodologies within different scientific fields. To integrate and analyze knowledge from different scientific fields, with data from empirical and theoretical literature, has been described as a way to extend existing knowledge into new insights and new holistic concepts [ 37 – 39 ]. Knowledge about gender norms in pain treatment can be found in the medical, behavioral, and social sciences, generated by quantitative and qualitative studies, theory development, systematical reviews, and so on. This review was theory-guided with a preunderstanding that gendered norms exist and influence the patient-provider relation and treatment decisions. However, first after the categorization of the reviewed studies, hegemonic masculinity and andronormativity were found as adequate theoretical concepts for a deeper analysis of the results.

3.1. Search Methods

A literature search was conducted using the following databases: PsycINFO, CINAHL, and PubMed. These databases were chosen in order to capture a broad spectrum of research from the medical, behavioral, and social sciences. The searches were limited to studies comprising human research subjects, articles written in English and published between January 2000 and April 2015. The following search terms were used, as text terms, applied to the whole article: chronic pain and femininity , chronic pain and masculinity , chronic pain and gender bias , chronic pain and gender stereotypes , and chronic pain and gender roles . The selection of search terms was theory-guided. That means, we did not review all literature about pain to examine if gender norms exist, but searched for articles that described them. The search rendered 688 articles; 175 duplicates were removed, and the other articles' title and abstract were read. The literature search was supplemented by a manual search, where relevant articles were retrieved from back references, citations, and a directed Google Scholar search. Even though the term gender roles was used, no study concerning transgender or other gender identities came up.

It has been argued that it is common practice to use the word “gender” when “sex” is meant, in health-care research in general [ 40 ], as well as in pain research in particular [ 6 , 41 ]. As a consequence, articles were removed when they clearly intended to examine sex differences despite using the word “gender.” Articles were also excluded when they did not relate to health-care services. Based on the criteria outlined above, 77 articles were selected for inclusion in the review; an overview of these articles is shown in Table 1 .

Included articles, sorted by type of journal and type of study design.

3.2. Data Analysis

The material was sorted into three theoretical categories corresponding to the research questions and thereby providing the study with a conceptual framework [ 42 ]. The theoretical categories were gendered norms about men and women with pain, gendered norms about how men and women cope with pain, and gender bias in the treatment of pain. The material in each theoretical category was further analyzed and coded into substantive categories which were more descriptive and closer to the categorized data [ 42 ]. With the amount of data in this review, it was particularly important to maintain a formal framework while at the same time allowing for new ideas and the identification of new relations between results. This was possible via the classification in both theoretical and substantive categories [ 42 ].

The theoretical and substantive categories are summarized in Table 2 . The first author conceptualized the theoretical and substantial categories and discussed them with the other authors until consensus had been reached. The review only used results from the studies included in the analysis. However, there is one exception (under Inexplicable—Unfit), also marked in the text, where definitions used in different studies were analyzed. Those definitions were usually not rendered as results but used throughout the articles.

Theoretical categories, substantive categories, and referenced articles; 77 articles reviewed.

During analysis, different patterns emerged which were further analyzed through the application of two concepts: hegemonic masculinity and andronormativity. This part of the review is outlined in the discussion section.

The selected 77 articles were published in 39 different journals, with studies published in journals specialized in pain dominating (32 articles). Different kinds of research design were represented, including quantitative and qualitative studies, reviews, and articles on theory development. However, only one of the studies with a qualitative design was published in a journal specializing in the field of pain. The distribution of the included articles over the 15 years varied between one and 12 articles/year, without any notifiable trend over time. All articles were conducted in high income countries—the United States, Canada, Western Europe, Australia, New Zealand, and Japan. Diagnoses that were examined included back pain (14), neck pain (5), musculoskeletal pain (9), fibromyalgia syndrome (5), osteoporosis (3), rheumatoid arthritis (2), ankylosing spondylitis, and headache. An overview over the included articles is presented in Table 1 .

The results were organized according to the three theoretical categories (also the research questions of this review) and their related substantive categories. An overview of all categories and corresponding articles is presented in Table 2 .

4.1. Gendered Norms about Men and Women with Pain

The studies reviewed showed a variety of gendered norms on how men and women experience and express pain and about patients with medically inexplicable pain conditions, such as fibromyalgia syndrome.

4.1.1. Stoic Men

In the studies reviewed, a clear pattern appeared, where men were presented as being stoic [ 6 , 8 – 10 , 13 , 14 , 43 – 50 ], tolerating pain [ 2 , 13 , 14 , 16 , 41 , 45 – 47 , 49 , 51 – 53 ], denying pain [ 8 , 45 – 47 , 51 , 53 , 54 ], and taking health risks even when they lead to increased pain [ 54 – 56 ]. Further, men were described as being autonomous [ 43 – 46 , 48 , 57 ], in control [ 43 , 45 , 46 , 48 , 50 , 57 , 58 ], avoiding seeking health care [ 5 , 8 , 13 , 44 , 45 , 54 , 55 ], not talking about pain [ 2 , 8 , 13 , 14 , 41 , 45 , 59 ], and avoiding talking about the possible relation between pain and psychic well-being [ 13 , 43 , 45 , 46 , 59 ]. One study interviewed male physicians about men seeking medical help: “All participants attributed men's lack of contact with health services to their need to appear ‘brave and manly' which making them reluctant to admit weakness” (p. 706) [ 44 ]. In a British study about men's view on masculinity and help-seeking, one participant said, “You don't like to make a fuss because it's a macho thing just to say you're being the strong and silent type … You'll endure it, you can take it. So if there is something wrong you won't talk to anyone about it. You have to be bed-ridden or half dead before you'll go (to the doctor's)” (p. 508) [ 45 ]. The description of the “stoic man” was the same, whether it was given by researchers [ 2 , 8 , 14 , 51 – 53 ], men with pain [ 43 , 45 , 46 , 54 , 55 , 57 , 59 ], or health-care professionals [ 13 , 44 ]. Yet, some studies pointed out that men also can experience vulnerability, distress, and suffering [ 46 , 48 , 59 , 60 ], sometimes combined with an unwillingness to talk about it [ 59 , 60 ].

4.1.2. Sensitive Women—In Comparison

Unlike the descriptions of men who were independent from women, the reviewed studies described women in comparison to men. Women were pictured as more sensitive to pain [ 2 , 9 , 13 , 14 , 41 , 47 , 53 , 61 – 63 ] and more willing to report pain than men [ 2 , 5 , 6 , 8 – 10 , 13 , 14 , 16 , 25 , 26 , 41 , 47 , 51 , 62 – 65 ]. It was also pointed out that it is more socially accepted for women than for men to show pain and talk about it [ 2 , 8 , 13 , 14 , 66 ]. In one study, health-care professionals gave different messages to men and women. “Be careful” messages were more often given to women, while “pain goes with heavy work” was more often given to men [ 67 ]. Some studies claimed that women, to a greater degree than men, are used to internal pain, because of menstruation and child birth [ 6 , 8 , 13 , 47 , 51 , 68 ]. Some researchers connected this to the presumption that women have greater body awareness [ 8 , 13 ], while others suggested that pain without an external cause is a natural characteristic of women's bodies [ 2 , 6 , 13 , 47 , 51 , 68 ].

4.1.3. Hysterical Women

The reviewed studies showed that women with pain can be perceived as hysterical [ 8 , 13 , 69 – 71 ], emotional [ 13 , 49 ], complaining [ 49 , 72 ], not wanting to get better [ 71 , 73 – 75 ], malingerers [ 71 , 73 ], and fabricating the pain, as if it is all in her head [ 47 , 49 , 71 , 74 , 76 ]. Other studies showed that woman with chronic pain rather are assigned psychological than somatic causes for their pain [ 13 , 22 , 47 , 49 , 69 – 71 , 74 – 79 ].

4.1.4. Inexplicable—Unfit

There are conditions where pain seems to be the only reported, visible, or measurable symptom. According to the reviewed studies, these conditions affect mostly women [ 8 , 13 , 53 , 69 – 71 , 75 , 80 – 82 ]. The reviewed studies demonstrated that “medically unexplained” conditions often go along with an unwillingness among professionals to believe in the women's pain [ 8 , 13 , 69 , 73 , 77 , 83 ]. In a Canadian study, general practitioners and specialists were interviewed about fibromyalgia patients [ 73 ]. They regarded fibromyalgia patients as malingerers, time consuming, and frustrating. Some clinicians even held the patients accountable for their pain [ 73 ].

Thirteen articles [ 6 , 8 , 22 , 53 , 69 – 71 , 75 , 77 , 80 – 82 , 84 ] in this review classified “medically unexplained” conditions in 19 different ways, for example, as pain without organic, observable, and objective symptoms [ 6 ]. The classifications are listed in Table 3 . Those definitions were usually not rendered as results in the reviewed studies, but used throughout them. This is the only section of this review where other parts than rendered results of the reviewed studies were included. The definitions given showed a clear focus on the absence of something (diagnostic evidence, organic pathology and so on), rather than the presence of something, which one of the studies also discussed in detail [ 70 ]. Medically inexplicable pain was described as a challenge for research and clinical practice to handle since these conditions do not easily fit into the traditional bioscientific medical system [ 6 , 69 – 71 , 77 , 80 ]. One researcher explained, “In fact, these conditions are called ‘contested illnesses' precisely because they represent a clash between biomedical knowledge and patient experience” (p. 834) [ 71 ].

Medically inexplicable pain conditions. List of classification terms and references among 77 articles reviewed.

The reviewed studies showed that legitimacy is crucial for pain patients [ 6 , 49 , 70 – 72 , 74 – 76 , 78 , 83 ]. Women's narratives about their experiences with clinicians showed, “(…) how hard they have had to work to be taken seriously, believed, and understood in medical encounters” (p. 1038) [ 72 ]. The encounter between the woman with chronic pain and her physician has been described as a struggle of both patients [ 76 , 78 ] and clinicians [ 73 , 83 ].

4.2. Gendered Norms about How Men and Women Cope with Pain

According to the studies reviewed, pain affects men's and women's identity and lifestyle in different ways. The role of gender and gender identity as a relevant factor for identity, lifestyle, and coping strategies in pain patients was illustrated by the reviewed studies.

4.2.1. Men's Gender Identity in Jeopardy

In summary, the reviewed studies meant that chronic pain did not alter men's identity [ 45 , 46 , 54 , 57 , 58 ]. Men with pain also strived to continue to live a normal life [ 43 , 48 , 54 , 56 , 58 , 59 , 85 ]. However, one study pointed out that the alteration of self-identity is common for both men and women with impairments [ 49 ]. Even if chronic pain per se did not seem to affect men's identity in general, there seemed to be a connection between chronic pain and men's gender identity. Men diagnosed with pain conditions that are predominant in women or suffering from chronic pain, which was perceived as feminine, described their suffering from pain as a threat to their sense of masculinity [ 43 , 48 , 54 – 56 , 59 , 60 , 85 ] leading to feelings of frustration [ 43 , 54 , 59 , 85 ], irritation [ 48 , 59 , 85 ], shame [ 48 , 54 , 56 ], and grief [ 59 , 60 ]. In a Danish study, a man with ankylosing spondylitis expressed this as “…a bloody dent in the masculinity that I can't lift my wife with one arm, and my two children with the other” (p. 35) [ 85 ]. Further, men with chronic pain were perceived by others—both laypeople and nurses—as being less masculine and more feminine than the typical man [ 50 ]. The same study also showed that women with pain were perceived as less feminine and more masculine than the typical woman and that men and women with chronic pain were considered to be more alike than the typical man and woman [ 50 ].

4.2.2. The Strong Body

The reviewed studies showed that paid work was important for men and that the role of the “breadwinner” was linked to their sense of masculinity [ 13 , 46 , 48 , 49 , 58 , 59 , 79 , 85 ]. They also displayed the functional physical body, including muscle strength, as a central part of men's gender identity. This was a recurring theme when men described their experiences of living with pain [ 43 , 46 , 48 , 54 , 56 , 57 , 59 , 60 , 85 ]. The importance of leisure activities, particularly sports, was highlighted [ 43 , 46 , 48 , 54 , 56 – 60 , 85 ]. A study on multiple chronic conditions later in life stated that more than half of the participants felt that their sense of masculinity was threatened when they could not participate in sports activities to the same extent as before [ 43 ]. An interview-study with men and women with chronic pain also showed that women, but not men were expected to cut down on leisure activities [ 58 ].

4.2.3. Men's Approach—This Is Not Me

The studies reviewed displayed different ways how men coped with pain as a threat to their masculinity. For instance, when men recognized their diagnosis as a “women's disease”, they questioned it, ignored it, or did not talk about it [ 48 , 54 – 56 ] and showed low compliance with physicians' advice [ 48 , 54 , 55 ]. In focus group interviews, men with osteoporosis described how they hid their “weakness” in public. They preferred to risk increased pain and new fractures rather than following the doctor's advice about not doing heavy lifting [ 54 ]. According to the reviewed studies, men also explained their pain with factors from outside, beyond the individual's control [ 46 , 56 , 57 , 60 , 68 , 86 ]. Ahlsen et al. stated, “By focusing on forces outside the men's influence and control, such as physical damage, bad genes and the nature of their work, the men's stories are often claiming the identity of being ‘good enough'” (p. 1770) [ 46 ]. The reviewed studies also showed that men considered it to be the health care's responsibility to restore their health [ 56 , 57 , 60 ]. For example, “In David's story, the responsibility of the self seems to be limited to keeping up with the training program, while it ultimately seems to be the health professionals' responsibility ‘to fix the problem'” (p. 364) [ 57 ]. In another study, a man with osteoporosis was quite clear about the role of health care: “I don't want to manage the pain. I want it eliminated” (p. 537) [ 56 ].

4.2.4. The Female Patchwork

The studies reviewed pointed out that women's identity was influenced by pain in combination with society's expectations, which included having a paid work, being a spouse and a mother, and being responsible for household and social relations [ 43 , 47 , 49 , 51 , 57 , 58 , 71 , 72 , 75 , 76 , 80 , 81 , 87 ]. It was also mentioned that women felt responsible for and prioritized family and household [ 13 , 43 , 47 , 49 , 57 , 58 , 79 , 80 , 87 – 89 ] and that health-care professionals encouraged them to do so [ 58 ]. In a Swedish study, more women than men were asked questions about household and family [ 22 ]. In a study on patients with low-back pain, married women with pain continued to perform household work to the same extent as before [ 89 ]. On the other hand, another study showed that men with musculoskeletal pain did not participate in household activities to the same extent as before and often handed these duties over to their spouses. Still, they saw their family role as unproblematic [ 58 ].

4.2.5. Women's Approach—I Have to Learn

In the reviewed studies, women faced complex demands [ 47 , 49 , 51 , 57 , 58 , 72 , 75 , 79 , 80 , 87 ] and tried to manage pain and the demands of their surroundings simultaneously [ 43 , 49 , 57 , 58 , 75 , 76 , 80 , 87 ]. According to the reviewed studies, the fact that women face complex expectations could explain why women use more and more complex coping strategies compared to men—for example, the use of social support [ 2 , 9 , 13 , 14 , 51 , 90 ]. Nevertheless, women's coping strategies were rated as less functional than men's, for example by health-care students [ 51 , 65 ]. Others found that men and women probably benefit from different coping strategies. It has, for example, been shown that men, but not women, benefitted from focusing on the pain [ 2 , 9 , 10 , 13 , 14 , 25 , 91 ].

It has been suggested that women with chronic pain have to learn to prioritize their duties and set limits to their surrounding [ 43 , 57 , 58 , 75 , 76 , 81 , 87 ]. In an interview study by Werner et al., women reported that they had learned during rehabilitation to explain their reduced physical capacity to their close ones and at work and to set limits for others' expectations [ 75 ]. It has also been reported that women who failed to manage their pain and demands from outside blamed themselves, which influenced their self-esteem negatively [ 49 , 75 , 80 , 87 ]. “Subjected to repeated experiences of not being heard, understood, or taken seriously regarding their invisible but long-lasting pain, the women could still experience doubt about themselves or feel that they were to blame” (p. 500) [ 75 ].

4.3. Gender Bias in the Treatment of Pain

The reviewed studies showed gender bias in the encounter, along with gender bias in prescribed medication. Differences in the treatment of men and women in these studies could not be explained by different medical needs.

4.3.1. Struggle for Legitimacy

In the reviewed studies, women with chronic pain frequently reported being mistrusted [ 57 , 72 – 75 , 78 , 87 ] and psychologized [ 72 , 74 , 78 ] by their health-care providers. In a study from Finland, women wrote narratives about the process of getting back pain diagnosed [ 74 ]. The results showed that doctors did not take the women's pain seriously and that the doctors' neglectful attitude became part of the problem [ 74 ]. Gustafsson et al. examined women's experiences of a rehabilitation program; women started out with a feeling of shame based on mistrust from professionals and misunderstanding from their families and friends [ 87 ]. However, women also reported that negative encounters with health care eventually changed to the better when they, often after long time, met a physician who believed them [ 57 , 72 , 74 , 87 ]. Tait et al. described a vicious circle. Feeling mistrusted or psychologized by health-care professionals can lead to distress. Pain, accompanied by distress, is typically attributed to psychological factors. If the patient articulates the distress, it can lead to an even greater degree of psychologization by health-care professionals [ 82 ]. Evolving a theory on women and chronic pain, Skuladottir and Halldorsdottir showed that professionals could empower women by being wise, competent, caring, and building a trustful relationship with them [ 81 ]. They could also reinforce gender norms via mistrust, disrespectful treatment, and making the women responsible for not being healthy [ 81 ].

4.3.2. How Do I Look (Appearances)?

The reviewed studies demonstrated that the appearance of women with chronic pain was judged by their doctors [ 6 , 13 , 49 , 75 , 78 , 83 ]. Some women were mistrusted when they looked too good, as in “you can't be sick,” while others were judged as unreliable if they did not look good enough [ 13 , 78 ]. “Statements like ‘You don't look ill', ‘You always look so healthy!', or ‘You are so young!' had made them feel irritated, sad, and frustrated, rather than flattered. Some of them said such statements indicated little understanding for how much pain they really had” (p. 1413) [ 78 ]. In experimental settings, the sex (and sometimes attractiveness) of the experimenter influenced participants' pain responses [ 2 , 5 , 6 , 8 – 10 , 14 , 15 , 51 , 53 , 82 , 92 – 94 ]. Pain threshold or tolerance tended to be higher, or pain reporting lower, when the experimenter was of the opposite sex, more pronounced for men than women.

4.3.3. Differences in Medication

The search for gender bias and chronic pain generated a number of studies on pain medication given to men and women [ 2 , 13 , 22 , 82 , 86 , 95 – 101 ]. The results of these studies showed that women, compared to men, received less and less effective pain relief [ 2 , 13 , 82 , 96 ], less pain medication with opioids [ 13 , 86 , 95 , 99 , 100 ], and more antidepressants [ 2 , 13 , 22 , 86 , 97 , 101 ] and got more mental health referrals [ 22 , 84 , 97 , 101 ]. In some of the reviewed studies, pain management decisions were affected by the clinician's own sex, thus interacting with the patient's sex [ 84 , 101 – 105 ].

5. Discussion

The purpose of this study was to review and condense literature on gendered norms about men and women with pain, gendered norms about how men and women with pain cope with their daily life, and gender bias in the treatment of pain. In the following, main findings are discussed and analyzed with theories related to the concepts andronormativity and hegemonic masculinity.

Among the main findings in this review was a distinct pattern of gendered norms described in pain literature, in line with hegemonic masculinity, that distinguished men's and women's perceptions, expressions, and coping with chronic pain. For instance, men were presented as being stoic, in control, and avoiding seeking health care [ 45 , 46 ]. Women, on the other hand were presented as being more sensitive to pain and more willing to show and to report pain [ 62 , 63 ], compared to men. These overall findings confirm a pattern of separation between men and women, not embedded in biological differences but gendered norms. The dichotomy between men and women has been described as a way to establish and maintain the gender order, allowing men's dominance over women [ 33 ]. That women were described in comparison to men can also be seen as a proof for andronormativity in health care, stressing that men, and health problems more often present in men, tend to be considered as the norm, while women (and other social groups outside the norm) are seen as irregularities. Since men are the norm and perceived as being “normal,” women are compared to them. Although women have more pain than men [ 3 , 7 ] and dominate most chronic pain diagnoses [ 3 , 7 ], they are described in comparison to men, as being deviant from the norm, even when they are in majority.

Another main finding was the pattern of andronormativity in relation to certain pain diagnoses. There are conditions where pain is the only reported symptom. Those conditions are highly dominated by women and have been described as difficult to fit in to the traditional bioscientific medical system [ 69 , 70 ]. They have low status in the medical hierarchy of diagnoses [ 35 ], and women with those diagnoses are often questioned as patients [ 69 , 83 ]. The concept of andronormativity implies that men and masculinity dominate health care to such an extent that women and femininity become invisible. Our results showed that symptoms in women-dominated conditions that do not fit the masculine norm actually seem to be invisible. The definitions of these conditions in the reviewed studies have focused on the absence of medically provable signs, for example, “pain in the absence of diagnostic evidence” or “pain without organic pathology.” Accordingly, those conditions were not defined in their own terms but in terms of what they lack—in relation to the predominant medical norm. Interestingly, even women with those “medically unexplained” conditions have been treated as if their illness does not exist. Our results showed that those women have been described as “malingerers” or as “if the pain is all in her head” [ 49 , 71 ]. An interesting finding worthy of future elaborations is that those pain conditions, which are predominantly suffered by women, are underexplored, and portrayed as a challenge for medicine [ 47 , 70 ]. It would also be interesting to further investigate if the key for change lies in the dichotomous construction of gender, which can lead to different diagnoses given to men and women, despite equal needs or in the masculine stamp of bioscientific health care, which can lead to different approaches to high- and low-status diagnoses.

Another major finding is that women's pain in the reviewed studies was psychologized [ 13 , 72 ]. According to hegemonic masculinity, psychological strain is feminine coded and at the same time down-valued in comparison to somatic conditions [ 32 ]. Consequently, when their pain condition is psychologized by health-care providers, women can feel that their pain is down-valued or dismissed, which in turn can cause stress [ 82 ]. Stress cues can, in turn, lead health-care providers to take patients' pain less serious [ 82 ], thus leading to a vicious circle. As long as stress and psychological strain are feminine coded, and a hierarchy between somatic and psychological findings exists in health care, there is a risk that not only the dichotomy between men's and women's pain, but also between somatic and psychological conditions is further consolidated.

Even men with chronic pain have to deal with hegemonic masculinity in health care. Physical strength is idealized in hegemonic masculinity, in opposition to weakness [ 33 ]. Chronic pain per se is a threat to idealized masculinities as pain generally goes along with loss of muscle strength. Our results indeed showed that physical strength was central for men's gender identity, whereas weakness threatened it [ 54 , 55 ], and that men with chronic pain risked to be perceived as more feminine than the typical man [ 50 ]. Imbedded in hegemonic masculinity is a competition for dominance among men, and the threat of losing masculinity is a threat of losing power [ 33 ]. Men in the reviewed studies showed different strategies, like denial and rejection, to deal with what could be described as a threat of losing masculinity ideals. An example is ignoring or questioning the diagnosis, or not following clinicians' advice [ 48 , 54 ]. Another interesting finding was that men according to the reviewed studies explained their pain with factors from outside, beyond their control [ 46 , 57 ]. This may be a way for men to express that pain is not a part of them and their identity and could be understood as the attempt to keep the position as a masculine man by separating the feminine coded pain from the masculine man.

A recurrent finding in the studies reviewed was women's struggle to try to handle pain and multiple demands from their surroundings simultaneously [ 75 , 76 ]. Traditionally, as part of the gender order, women are responsible for their home and family and to take care of themselves. However, our results showed that an overload of responsibility for family, work, household, their pain, and their wellbeing seemed to be an obstacle for recovery for women with pain [ 49 , 87 ]. Our results also showed that health-care providers considered it important that women learn to say “no” to demands from others [ 75 ]. Even if this may be thought as an attempt to lower women's overload of responsibility, it can actually increase women's responsibility [ 75 ]. This could be explained by hegemonic masculinity, where the subordinate part is expected to conform to the prevailing norm, making women responsible to solve their issue and also being responsible for the outcome. The consequences of hegemonic masculinity can increase the burden on women with chronic pain, as the reviewed studies showed.

In summary, our results confirmed a paradox, highlighted by Hoffmann and Tarzian [ 13 ]; compared to men, women have more pain, and it is more accepted for women to show pain, and more women are diagnosed with chronic pain syndromes. Yet, paradoxically, women's pain reports are taken less seriously [ 13 , 71 , 78 ], their pain is discounted as being psychic or nonexistent [ 69 , 70 , 72 ], and their medication is less adequate than treatment given to men [ 2 , 96 ]. This has been described as a paradox [ 13 ] but can be explained as an expression for hegemonic masculinity and andronormativity in health care.

5.1. The Relation between Gendered Norms and Gender Bias

Several researchers [ 2 , 3 ] have emphasized the risk of gender bias in the treatment of pain; however, studies that demonstrated objectively measurable gender bias in medical treatment were less extensive and less consistent. Subjectivity in the assessment of pain makes pain experiences and pain treatment sensitive to gender norms [ 2 , 12 ]. In addition, it is also reasonable to conclude that the subjectivity makes it difficult to prove malpractice related to gender. Nevertheless, when we searched for gender bias in pain, we found studies that showed that women received less adequate pain medication and more antidepressants compared to men [ 86 , 98 ]. In addition, a pattern of parallels between gendered norms and gender bias could be demonstrated in the results. For example, gendered norms were expressed through presumptions such as “women are more emotional than men” [ 49 , 71 ]. The psychologizing of women's pain [ 13 , 70 ] reflects this norm, and that antidepressants are more often described to women compared to men [ 22 , 97 ] could be a consequence of it.

5.2. Consequences of Gendered Norms in Health Care

The notion of men and women as separate and different in manners and needs is problematic [ 106 ], as it can consolidate gendered norms, which in turn can lead to individual needs being overlooked [ 106 ]. Health is constituted within a wide range of gender-related experiences [ 106 ]. The patient-provider relation is one domain for constitution, reinforcement, or challenge of gendered norms, where andronormativity and hegemonic masculinity can cause health-care providers to treat men and women based on gendered norms rather than individual needs. For instance, gender norms like “men need to be physically strong” [ 43 , 54 , 58 ] can lead to the presumption that active leisure time is more important for men than for women, which in turn can lead health-care professionals to recommend men, but not women, to continue with sport activities despite their pain [ 54 , 85 ]. Or, as another example, if women are seen as the primary care giver and responsible for family and household [ 49 , 58 , 71 , 80 ], this can lead professionals to recommend women, but not men, to prioritize family above work and leisure time [ 22 , 58 ]. Increased awareness of gendered norms and potential gender bias is a prerequisite to counter gender bias in health care [ 20 ]. There is a power imbalance between men and women, and many (though not all) gender biases are to women's disadvantage [ 20 ]. However, both men and women are restricted by gendered expectations, and both men and women profit from more equitable care [ 3 , 20 ].

5.3. Methodological Considerations

This review was theory-guided with a preunderstanding that gendered norms exist in health care, which has influenced the selection of our search terms. Our directed literature search might be criticized as it potentially excluded studies that did not find/report gender differences. However, the aim of this study was not to prove if gendered norms in health care exist, which earlier research already has shown [ 2 , 3 , 13 ], but to collect and analyze gendered norms and gender bias as described in pain literature and deepen the knowledge about them. Our results support the idea that there is hegemonic masculinity and andronormativity in health care, and several patterns of gendered norms and consequences thereof could be explained by hegemonic masculinity and andronormativity. It might be important to underline that these theoretical concepts were not chosen in advance but found applicable after the categorization and analysis of the reviewed studies.

Another concern addresses the large number of included studies, providing a risk for fragmentation and selective interpretation of their content. This was balanced by the coding in three distinct and clearly defined theoretical categories, which provided a tight framework for the selection of relevant material [ 39 , 42 ]. All authors discussed and agreed also on all categories. The descriptive basis of the substantive categories allowed to capture different patterns. There might be other patterns to be found in the reviewed studies. However, our findings were consistent throughout the reviewed studies and provided new insights, which should be further examined in both qualitative and quantitative studies.

A common dilemma in gender research involves how to create awareness about stereotypes without confirming or reinforcing them [ 40 ]. The purpose of this study was to challenge stereotypes about men and women, not to emphasize the differences. Gender norms are not the only norms that influence treatment decisions and patient-provider relations in health care. For instance, presumptions on age, race, and educational level have an impact on pain and intersect with each other and with gender [ 3 , 97 , 102 ], which is an important field for further elaboration.

6. Conclusions

Gendered norms about men and women with pain, present in research from different scientific fiends, illustrate prevailing hegemonic masculinity and andronormativity in health care. Yet, the notion of gender is a construction and can be changed. Awareness about gendered norms and that they can lead to a consolidation of the dichotomous depiction of men and women is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

Authors' Contributions

Anke Samulowitz carried out the literature searches and was as the main party responsible for design, analysis, and writing. Ida Gremyr, Erik Eriksson, and Gunnel Hensing contributed to design, analysis, and writing. All authors read and approved the final manuscript.