In recent decades, there has been progress towards closing the gap in career opportunities for men and women, but further efforts are still needed to achieve equality. Official data from 2017 show that while the proportion of women with university degrees education is greater compared to the proportion of men in Spain and in Europe,1,2 the rate of unemployment is higher in women.3,4 Disparities in the burden of informal caregiving in households and career interruptions associated with motherhood are some of the determinants at play in the lower representation of women in positions of power in industry and in academic and research institutions.5 This phenomenon is known as the glass ceiling6 and explains actual inequalities, such as women amounting to only 21% of teaching positions in higher education in Europe and the United States, the higher proportion of women in part-time or temporary positions and the wages of women being up to 18% lower compared to men.7,8 In Spain, women amount to only 39.9% of the teaching and research staff in public universities and 20.8% of tenure positions.9

Glass ceilings also manifest in public health and health care institutions. Studies in Spain and abroad have evinced the inferior representation of women in executive and management positions of scientific associations and societies and in the editorial boards of scientific journals.10–14 A review conducted in 2014 of the management of 173 scientific associations in Spain found only 41 female presidents (22.5%). Also, only 32.4% of management positions and 36.2% of the seats in executive boards were filled by women.10 According to a study published in 2010 that analysed 172 Spanish biomedical journals, only 13% were led by women.13

Research output has a become very important factor in career advancement in the health care field. For the first time in history, in 2017 the number of female doctors exceeded slightly the number of male doctors in Spain.15 The proportion of female doctors in Europe in the same year was 49%.16 In spite of these, there are substantial differences between the sexes (gender gap) in the authorship of scientific publications. A review of the articles published over 35 years in 6 journals with a high impact factor found a lower proportion of women in the first and last listed authors.17 There was an increase in the proportion of female first authors from 5.9% in 1970 to 29.4% in 2004, and of last-listed (senior) authors from 3.7%–19.3% in the same period. Although the number of female authors of articles has increased compared to previous decades, this increase varies based on the type of article. Thus, studies of national and international scope demonstrate that the number of female authors commissioned pieces (editorials) by journals continues to be substantially smaller compared to the number of male authors, rarely exceeding 20% of the total.17–21

Several recent articles have focused on the research output in paediatrics.20,22 A study on gender differences in authorship in 3895 original articles published in Pediatrics, JAMA Pediatrics and The Journal of Pediatrics (2001–2016)22 found an increase through time in the percentage of female first authors, which reached 57.7% in 2016, with a slower advance in the percentage of female senior authors (38.1%). These findings were similar to those of another study published in Anales de Pediatría analysing data for 2017,23 which concluded that editorials and special articles were commissioned to female authors less frequently (35.0%).

The growing awareness of some scientific journals of the gender gap in research output has spurred articles analysing this phenomenon and offering recommendations to close the gap.24–26 In 2016, Anales de Pediatría joined the ranks of the journals publishing the full name of authors, facilitating a perspective on gender in its publications.27,28 Although there are signs suggesting advances toward greater equality, this progress is greater in medical specialities more likely to be chosen by women, such as paediatrics. There is an increasing trend in the representation of women in leadership positions in paediatrics journals and associations in Spain.29–31 However, the current evidence shows that measures still need to be implemented to guarantee progress toward gender equality both in paediatrics and in other medical specialities in Spain.

The objectives of our study were: 1) to determine the position of Anales de Pediatría relative to other Spanish journals in regard to the gender gap and 2) to analyse gender disparities in the scientific output of the main Spanish medical journals.

We conducted a cross-sectional study of authorship in the articles of the main Spanish scientific journals indexed in the SCImago Journal & Country Rank portal,32 a public online portal that provides bibliometric indicators for scientific journals based on data from the Scopus® database. The SCImago Journal Rank is computed using an algorithm that weights the citations received by each publication in the past 3 years based on the prestige of the citing journal.33

We established 2 units of analysis: journals and articles. The main sources of the data for our study were the SCImago Journal & Country Rank (journals) and the websites of the included scientific journals (articles). The terms we used in the portal to obtain data for the journal unit were: subject area = medicine, subject categories = all, country = Spain, type = journal and year = 2017 (last available year).34 The search identified 152 journals, to which we applied the following exclusion criteria: ranking in the 4th quartile or not specified, language other than Spanish, country other than Spain, non-medical content, no content published in 2017 and use of initials in author names. The total number of journals included in the analysis was 24 (Fig. 1). We collected data for the articles unit by reviewing all the articles published in 2017 in the 24 journals, excluding the following types: in memoriam, acknowledgments, special collaborations, prizes and awards, congress abstracts and errata. The total number of articles included in the analysis was 3375. Table 1 presents the characteristics of the included journals and articles.

Figure 1.

Flow chart of journal selection.

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To pursue the first objective, we performed a bivariate analysis describing the sex of the authors in every article in each journal by means of absolute and relative frequencies. We determined the sex of the author based on the full name. In case of unusual names, we consulted the first and last name database of the Instituto Nacional de Estadística (National Institute of Statistics),35 assigning the sex corresponding to the greater proportion of individuals with that name in Spain. We assigned the “unidentified sex” category to names not included in that database. To compare the participation of women in the authorship of each journal, we calculated the female-to-male ratio for the total signing authors in each journal. We defined “high participation” as a ratio greater than 1.20, and “low participation” as a ratio lower than 0.80. We extrapolated these cut-off points from the Organic Law on Equality 3/2007,36 which establishes as acceptable a maximum difference of 20 percentage points in general public settings. We have expressed quantitative variables (number of female authors, number of male authors and total signing authors per article) as absolute frequencies, mean and standard deviation (SD).

We pursued the second objective of our study with the journals analysis unit by means of bivariate analyses, calculating the female-to-male ratio for the total of signing authors to compare the participation of female authors in different types of articles. We also performed bivariate analysis comparing the dependent variable (type of article) and different independent variables (sex, affiliation and country of the first and last authors). When more than one affiliation was reported for a single author, we selected the affiliation that was listed first. We eliminated observations missing information on one of these independent variables, which left a total of 3303 observations for the first author and 3067 for the last author. We used the χ2 test or the Fisher exact test in case of expected counts of less than 5. Lastly, we fitted binary logistic regression models to perform the multivariate analysis. To this end, we created dichotomous qualitative dependent variables based on the type of article for the categories editorial, letter to the editor/director, original article/brief original article and case reports/scientific letters/images. We defined statistical significance as a p-value of less than 0.05. We calculated the odds ratio for the sex of the first and last author adjusted by affiliation and country (aOR) with the corresponding 95% confidence intervals (CIs). We performed the analysis with the software R, version 3.5.1.

Since category assignments in the analysis of the 3375 articles were not automated, we performed a quality control analysis of the database. We reviewed the first original article in every issue of the journals, detecting errors in 4.6% and 3.6% of the 195 reviewed articles in the identification of the gender and affiliation of the first author and in 2.6% and 5.6% of the articles in the gender and affiliation of the senior authors, respectively.

We included a total of 3375 articles published in the 24 medical journals included in the study. The 6 journals with the highest output were Medicina Clínica (12.3%), Revista Española de Cardiología (8.9%), Revista Española de Enfermedades Digestivas (8.3%), Archivos de Bronconeumología (7.6%), Nutrición Hospitalaria (7.5%) and Anales de Pediatría (5.0%). Combined, these journals account for nearly half of the total articles (49.6%) (Table 1).

The total number of authors of both sexes listed in the 3375 articles was 16 252 (mean, 4.81; SD, 3.33). Of all authors, 44.2% were women, 53.9% men and 1.9% of unidentified sex. The mean number of female authors per article was 2.13 (SD, 2.05) and the mean number of male authors, 2.60 (SD, 2.34). After excluding observations in which we could not identify the sex of an author, we found that 46% of the 3308 first authors and 33.5% of the 3071 senior authors were women.

The journals with a greater participation of female authors were Farmacia Hospitalaria (female-to-male ratio, 1.78), Anales de Pediatría (1.36) and Gaceta Sanitaria (1.22). Ten journals had low rates of female authorship, and 11 had equal distribution (Table 2).

The most frequent types of articles were original articles (30.8%), followed by scientific letters-case reports-images (27.3%) and letters to the editor/director (17.5%) (Fig. 2). The bivariate analysis of all signing authors by sex and type of article for the total articles in every journal found a predominance of male authors over female authors in every type of article, with female-to-male ratios lower than 0.80 for the editorials (0.43), scientific letters-case reports-images (0.77) and other articles (0.64) (Table 2).

Figure 2.

Distribution by type of article.

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Table 3 presents results of the bivariate analysis of the type of article and sex, affiliation and country of the first author. With the exception of original articles-brief original articles, we found a higher proportion of male authors in all other types of articles. Of the 302 editorials included in this analysis, 81 (36.7%) had a female first author. Of the total of female first authors, 5.3% corresponded to authors of editorials, compared to 12.4% of male first authors (P < .001). However, when we analysed original and brief original articles, we found a greater proportion of female first authors compared to male first authors (40.9 vs 31.5%; P < .001), with a gender gap of + 9.4% in favour of women. When it came to the affiliation of the first author in relation to the type of article, we found a higher proportion of authors employed in primary care in the letters to the editor/director (29.0%), of authors employed in research centres or universities in the original and brief original articles (58.8%), and of authors engaged in speciality care in the scientific letters-case reports-images (34.1%) (P < .001). Last of all, the comparison of the type of article and the country listed for the first author revealed statistically significant differences in the original and brief original articles and the scientific letters-case reports-images, with a greater proportion of first authors not from Spain in case of the original articles and original brief articles (43.7 vs. 34.1%) and a greater proportion of first authors from Spain in scientific letters-case reports-images (20.4 vs 28.6%) (P < .001). In the binary logistic regression analysis of the type of article by sex, affiliation and country of the first author we found statistically significant aORs for the variable sex (female vs male author) in editorials (aOR, 0.39; 95% CI, 0.30−0.51) and original and brief original articles (aOR, 1.55; 95% CI, 1.33–1.80) (P < .001) (Fig. 3).

Figure 3.

Odds ratio of multivariate analysis considering the type of article and author sex adjusted for author affiliation and country.

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When it came to the bivariate analysis of the type of article by sex, affiliation and country of the last author, we found distribution trends similar to those observed in the analysis of first authors (Table 4). We found a male predominance in the senior authors of all 4 types of articles under study. This was also the case of original and brief original articles, in which we found no statistically significant differences (P = .326). Of the 200 editorials analysed, 42 (21%) listed a female senior author and 158 (79%) a male senior author. In the multivariate analysis of authorship of editorials by sex, affiliation and country of the senior author, we only obtained a statistically significant aOR in the comparison of female versus male authors: 0.50 (95% CI, 0.35−0.70) (Fig. 4).

Figure 4.

Odds ratio of multivariate analysis considering the type of article and senior author sex adjusted for author affiliation and country.

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The results of our study evince gender inequality in the authorship of articles published by the leading Spanish medical journals in 2017 analysed as a whole. However, we found substantial differences between journals in the sex distribution of authors. The female-to-male ratio of the 24 journals analysed ranged from 0.36 (Archivos Españoles de Urología) to 1.78 (Farmacia Hospitalaria).Anales de Pediatría is the second leading journal in terms of the participation of women authors (1.36).

The number of female authors was lower compared to the number of male authors both in the analysis of the total of signing authors for all the articles in all the included journals and when we only analysed the first- and last-signing authors. The differences were greatest when it came to the senior, last-signing author. The analysis by type of article and by sex revealed that male authors exceeded female authors in all types of articles except in the case of first authors of original articles. These findings were consistent with those of previous studies17–23 and support the hypothesis of female first authors being expected to work on tasks that require more effort in the publication of a manuscript.37 The predominance of men among senior authors in most types of articles may be an indirect marker of gender inequality in positions of leadership and power in top management positions in health care facilities and research centres and in the funding of research projects led by women.7,8,24,25,38

The results of the analysis of the secondary independent variables, the affiliation of the author and the country of origin, revealed the association between the time available to the author to devote to research and scientific output. Thus, professions involving clinical practice and Spain as the country of origin are associated with the publication of fewer original articles in the Spanish journals included in our study.

These findings were consistent with those of other studies conducted in Spain and in other countries11,17–22 as regards gender inequalities in scientific output. While there has been an increasing trend in the scientific output of women at the international level,17,19 it continues to be less than the output of men, despite women amounting to 50% or more of professionals in medicine.7,8,15,24 Our study adds to the scientific evidence demonstrating the gender gap in scientific journals by type of article, with a greater frequency of women signing as first authors in original articles and a greater frequency of men signing as first and last authors in editorials.21–23 These findings may reflect the presence of unintentional gender biases in favour of men when it comes to the selection of authors for articles commissioned by journals, which would not manifest in spontaneously submitted articles subject to peer review.7,14,37

One of the strengths of our study is the large number of authors (n = 16 252) and articles (n = 3375) analysed, all from the 24 Spanish medical journals that are most relevant in the current scientific scene. The inclusion of 2 units of analysis allowed us to differentiate scientific output by sex in each journal and by type of article. The analysis of both the total number of signing authors and of the numbers of first and last authors contributes information on the scientific output of each sex at different levels. And the multivariate analyses adjusted by author affiliation and country of origin complemented these results with impact indicators. Some of the limitations of our study include the potential risk of bias due to nondifferential misclassification in relation to the erroneous determination of the sex of the author, which, given the quality control analysis that we performed, could have amounted to 4.6% of first authors and 2.6% of last authors, a percentage comparable to the percentage reported by a study performed with similar methods.19 On the other hand, the proportions of female and male authors in a journal may be affected by the number of female and male clinicians active in each speciality. To adjust for this potential effect, we sent a message to the official e-mail addresses of the journals and the associations they were affiliated to asking about the sex distribution of members in the speciality that was the focus of the journal, but due to the low response rate we were unable to assess the impact of this factor in our analysis.

The participation of female authors in the scientific output of Anales de Pediatría is high. These are encouraging data in regard to the fight against gender inequality, but additional studies are required to determine the extent to which these positive outcomes can be attributed to the greater number of female paediatricians today. Furthermore, we invite a reflection on the causes of the persisting gender gap in senior authorship and the commission of editorials by the journal, the sex distribution of peer reviewers (40.4% women)39 and the sex distribution of the editorial committee (29.5% women).31 The development of a gender equality policy in scientific publications could contribute to this goal.40