Background
Defining Leadership
There is no singular definition of leadership in the literature (35-38). Over the years educational theorists have characterised leadership based on various attributes, behaviours, actions and outcomes. Theories include the great man theory, trait, behaviour and contingency leadership theories (including Fred Fiedler Model, Hersey-Blanchard Situational Model, Robert House Path-Goal Model and Vroom-Yetton Model), charismatic and transactional leadership, feminist leadership, as well as transformational leadership (39-41).
Although there is significant overlap among leadership types, the literature suggests women lead differently to men, with female leadership more commonly associated with a democratic or participatory style, rather than an autocratic ‘task-oriented’ masculine leadership style (41-43). Acknowledging these ‘gender’ influences on leadership is invaluable, especially when we are considering why gender leadership diversity might influence organisational outcomes (44). Understanding these ‘gendered’ leadership traits also plays an important role if we are to address the implicit gender biases and structural barriers often present for women seeking leadership opportunities (45, 46).
Within medicine, leadership is more commonly based on authority-roles, not the aforementioned leadership types (47-49). Heads of hospital units and departments, heads of post-graduate medical training, elected counsellors for training and accreditation, counsellors and presidents of medical representative bodies, are the typical leadership positions identified within the medical literature (12).
Medical leadership in Australia and New Zealand
Within both hospitals and postgraduate colleges in Australia and New Zealand, male specialists hold the majority of medical leadership positions (2). This is despite the rapid feminisation of medicine over the last two decades seen both nationally (6, 7, 50) and internationally (51-54). An optimist viewing Australia’s recent medical feminisation would anticipate a natural correction of the gender leadership imbalance over time (33, 55). However female specialists still appear to ‘hit the glass ceiling’ when progressing toward medical leadership roles (42, 56- 60). Indeed, medicine is not the only feminised profession in Australia with a gender leadership gap. Prior to the feminisation of medicine, both veterinary science and education became feminised professions (61, 62). Despite their ‘pipeline’ they too have experience a persisting gender leadership gap. If medicine is not unique in its leadership inequity, this suggests the consideration of a wider societal gender imbalance in power and opportunity for women seeking leadership.
There are two key problems that flow from this type of gender leadership gap. First gender inequity in leadership raises the question of authentic representation. Can a professional organisation achieve authentic representation if its leadership does not reflect or represent its membership? The second concerns the impact of exclusive male leadership style. Does this reduce the likelihood of co-operation and collaboration, the more often feminised leadership traits, with the membership? And where does this leave each profession’s ethical responsibilities with regards to membership democracy and equality, when evidence suggests men and women equally desire leadership roles (63)?
Barriers for women seeking leadership
There is a general trend of persistent underrepresentation of women leaders in business, science, education, research and public office (32, 64-69). Similar trends are apparent in healthcare, where although women increasingly represent a gender majority, they remain in the leadership minority (70, 71). Three main factors appear to influence how and why women are under- represented in leadership.
The first factor is the developmental impact of childhood exposure to leadership factors. Wojtalik et al (2007) explored the influence of childhood on women’s leadership aspirations (72). Building on work by Eccles (73, 74), this study revealed a strong relationship between parental leadership expectations and leadership success. Without a parental-led gender-fair childhood environment, Wojtalik et al found women were likely to limit their leadership aspirations. Aligning with current gender schema theory, this study asserts that the developing child internalises the gender lenses of the dominant culture (75).
A second influence includes structural factors including explicit and implicit gender bias, gender stereotypes and schemas, and structural barriers (42, 76-79). Valian describes how our gender schema for women (nurturant, expressive, communal and empathic) is at odds with that of our masculinised schema for leadership (agentic, assertive, and task-oriented), leaving women under-evaluated with respect to performance. Adding to this is evidence that women more consistently rate themselves less capable than male colleagues (80, 81).
The third influence occurs once women are in a leadership role, with women judged more negatively as leaders compared with male counterparts (82, 83). This negative evaluation creates yet another deterrent for women seeking leadership, as well as driving internalised stereotypes and influencing women’s adoption of more masculinised styles of leadership (84-87). Even when matched as ‘effective’ leaders, the literature reveals males consistently rate women lower in performance (88), while women are more likely to be placed in ‘high risk’ leadership positions often associated with shorter tenure (89). This is further amplified in highly masculinised organisations and when a larger percentage of males are the evaluators (90).
Within medicine, international research has identified a number of similar cultural, structural, organisational and personal barriers to women entering leadership roles (77, 80, 91-96), and these remain consistent for women desiring medical leadership in Australia (97, 98). These have not been explored in the discipline of obstetrics and gynaecology in Australia and New Zealand.
Why aspire to gender leadership equity?
Gender equality is a fundamental human right and a primary tenant of social justice (65, 99, 100). This alone should drive our cultural reform for gender equity in all areas, including leadership, of society. Beyond fundamental human rights, the literature reveals gender equality improves workplace productivity, emotional wellbeing, economic growth, and organisational reputation (21, 44, 68, 101-103). Leadership gender diversity has also demonstrated improved financial and organisational performance (102, 104, 105). There are further established advantages to gender equality at all levels of the workplace. These include organisational revenue, improved gender equality is estimated to increase GDP (gross domestic product) 12% by 2050 in European Union countries (24) and increase by 2025 increase global GDP by 26% (106, 107).
Medical leadership equity
The international and national literature across medicine reveals a consistent trend of fewer females in medical leadership, and this remains irrespective of the gender balance within each specialty (2, 13, 16, 58, 59, 108). Whilst addressing gender leadership inequity at any level is valuable, gender bias exists and shapes the landscape long before postgraduate training and specialist practice (42, 109). One solution to addressing leadership inequity is to address this issue early within medicine (98, 110-112). Within the United States the Association of American Medical Colleges (AAMC) Academic Project Committee has now introduced medical school curriculum reform designed to address gender leadership disparity (113). These include interventions to improve mentoring, limit gender bias, and reduce structural biases for women (29, 114-116). Reviewing the leadership landscape over time will reveal the true effectiveness of this curriculum cultural reform. No such program exists currently within the national Australian medical school curriculum.
Acknowledging the gender leadership gap is another step towards minimising the gender inequity in medical leadership (42). Achieving gender equality will require numerous changes, not only increasing the number of women in male-dominated medical specialties, but also addressing the impact of explicit and often unconscious gender-linked biases within medicine (77, 91, 117, 118). Advocacy for broadening gender roles in society and the professional identities of women in masculine professions will be a deeply relevant part of this cultural reform (110). Within Australia, the past president of ANZCA (Australian and New Zealand College of Anaesthetists) recently addressed this issue within her own postgraduate setting (16). Although lacking reference to what barriers exists, Professor Kate Leslie acknowledged the discord between gender representations within the leadership and membership. Embracing Martin’s (119) simple rules for improving leadership diversity, and following recommendations from the American Society of Anaesthesiology (120), Leslie implores the ANZCA community to model its leadership on the gender and racial diversity of its membership.
The role of gender quotas
There are several strategies that have been employed to decrease the gender inequality in the workplace. A prominent example of this is positive discrimination, with measures aimed at improving ‘equality of opportunity’ for people who face, or have faced, entrenched discrimination (100). Gender quotas, with stipulated minimum gender representation, provide one method for improving gender diversity in organizations. One of the questions addressed by this research is whether gender quotas would be supported by the RANZCOG membership.
Within politics, an industry with a long history of quota use, the international ‘Gender Quota’ database indicates gender quotas (legislated candidate quotas, reserved seats, or quotas adopted voluntarily by political parties) have seen female parliamentary and legislator representation improve internationally from 13% in 1990 to 23% in 2016 (121). This increased female representation has in turn increased legislations focused on ‘women’, with subsequent improvement in both women and perinatal health outcomes (122-124). In this setting, positive discrimination has improved both political gender diversity, as well as health outcomes for women. In 2005 Norway mandated a female gender quota of 40% for board representation on all public limited liability companies. This saw a numerical increase in female ‘board’ representation as well as the additional positive effects on female leadership in ‘non-board’ roles. In this setting gender quotas positively improved gender diversity, and created a ‘new culture’ embracing female leadership (125).
Within the broader field of gender theory there are many arguments both for and against the role of gender quotas. Quotas have a tendency to promote essentialism, the conviction that individuals represented through quotas have essential traits that define them (126, 127). Within the gender quota arena this would suggest only women can represent women, and that all women represent all types of women. This is however not true. Quotas may be also seen to threaten the principle of equal opportunity for all, as well as promote a ‘non democratic’ process (128, 129). Counter to this are the arguments for gender quotas. These include non-essentialism considerations such as structural biases for women in the workplace. An example of this is the near-universal supposition that women take primary responsibility for early child rearing (with more part-time work and career breaks), reducing opportunities for career progression. In this setting gender quotas facilitate ‘gender equality’ by acknowledging and overcoming structural biases faced by women desiring leadership. Another advantage of gender quotas is the ability to truly provide representation where leadership gender might be discordant with the population.
Are there solutions to the medical gender leadership gap?
An acknowledgement of the gender leadership gap, as well as addressing underlying institutional and individual gender schemas, is vital to the correction of this inequality (130). Several authors have written on corrective strategies addressing the gender leadership gap. Beyond gender quotas, multiple solutions including; effective succession planning, implementation of leadership development programs focusing on gender diversity, interventions facilitating behavioral changes, adoption of objective performance evaluation process, and creation of institutional initiatives including flexible work schedules, mentor programs, networking events, and institutional women networks, have been discussed in the literature (70, 131-136). Within medicine, mentoring appears as a commonly voiced solution (116, 137-142). Challenging this solution however is the low number of women currently within medical leadership roles, reducing the availability of same-sex mentors and role models for junior faculty (143-146). At the core of all solutions however must be a desire and acceptance of cultural reform for gender equity, advocated by the woman, the institution and society. Only then can true gender leadership equality occur.