Molly Carnes, MD, MS Professor, Depts of Medicine, Psychiatry, and Industrial Systems Engineering University of Wiscons

1. Thank you for inviting me to speak to you about a topic I have been interested in for the past 10 years because it is something I live. That is, studying why women are not advancing into leadership positions in academic health sciences when there have been plenty of women in the pipeline since the early 1980�s. Much of the work I have done focuses on gatekeeping junctures in an academic career because we see that on the other side of each of these gates there are fewer and fewer women of any ethnicity/race and fewer men and women from URM groups.Thank you for inviting me to speak to you about a topic I have been interested in for the past 10 years because it is something I live. That is, studying why women are not advancing into leadership positions in academic health sciences when there have been plenty of women in the pipeline since the early 1980�s. Much of the work I have done focuses on gatekeeping junctures in an academic career because we see that on the other side of each of these gates there are fewer and fewer women of any ethnicity/race and fewer men and women from URM groups.

2. What is �unconscious bias� Unconscious bias and assumptions Previously held beliefs about a social category Schemas Stereotypes Mental models Cognitive shortcuts Statistical discrimination Implicit associations Spontaneous trait inference The tendency of our minds to judge individuals based on characteristics (real or imagined) of groups Of course we all know about conscious biases, prejudice, bigotry, frank sexism and racism � but in my work, I give the benefit of the doubt that we are dealing with individuals that are sincerely committed to increasing the gender and racial/ethnic diversity of the healthcare workforce � clinicians, educators, and researchers. Nice wording (from Araya et al., 2002 �Previously held beliefs about a social category are used in forming an impression of an individual member of that category.� �An impressive body of research has clearly established that stereotypes, as well-learned sets of associations, can be activated spontaneously or automatically in the presence of a stimulus cue in the environment.� �Stereotypes often lead to biased information processing and negative evaluation of stigmatized groups� Several research findings indicate that activated stereotypes may not be applied to subsequent judgments. Statistical discrimination is an economic theory of inequality based on group stereotypes. In its simplest version, individuals are discriminated against because stereotypes are held against the groups they are associated with. This type of preferential treatment is labeled "statistical" because stereotypes may be based on the discriminated group's average behavior. Of course we all know about conscious biases, prejudice, bigotry, frank sexism and racism � but in my work, I give the benefit of the doubt that we are dealing with individuals that are sincerely committed to increasing the gender and racial/ethnic diversity of the healthcare workforce � clinicians, educators, and researchers. Nice wording (from Araya et al., 2002 �Previously held beliefs about a social category are used in forming an impression of an individual member of that category.� �An impressive body of research has clearly established that stereotypes, as well-learned sets of associations, can be activated spontaneously or automatically in the presence of a stimulus cue in the environment.� �Stereotypes often lead to biased information processing and negative evaluation of stigmatized groups� Several research findings indicate that activated stereotypes may not be applied to subsequent judgments. Statistical discrimination is an economic theory of inequality based on group stereotypes. In its simplest version, individuals are discriminated against because stereotypes are held against the groups they are associated with. This type of preferential treatment is labeled "statistical" because stereotypes may be based on the discriminated group's average behavior.

3. Three Examples Semantic priming Linguistic expectancy bias Language that ignores or blames women Abstraction to reinforce stereotype-congruent information Abstraction to reinforce stereotype-congruent information

5. Three Examples Semantic priming Linguistic expectancy bias Language that ignores or blames women Semantic priming refers to the way in which exposure to words that are in some way associated with a social category, influence subsequent evaluation of someone in that category. We will be particularly in the social category of gender, but research has also looked at race, age, and skinheads.Semantic priming refers to the way in which exposure to words that are in some way associated with a social category, influence subsequent evaluation of someone in that category. We will be particularly in the social category of gender, but research has also looked at race, age, and skinheads.

6. Semantic priming activates unconscious gender stereotypes Unrelated exercise: unjumble sentences where actions reflect dependent, aggressive or neutral behaviors; e.g.: P alone cannot manage a M at shouts others of R read book by the �Reading comprehension� experiment with Donna or Donald engaging in dependent or aggressive behaviors Rated target on series of traits (Likert, 1-10)

7. Banaji et al., J Pers Soc Psychol, 65:272 1993 Gender of target determined influence of semantic priming: Neutral primes � Donna and Donald same Dependent primes � only Donna more dependent Aggressive primes � only Donald more aggressive

8. NIH Director�s Pioneer Awards All 9 went to men in the first round (2004) Was it only because their science was the �best�? Many features of the solicitation and review process would predict preferential selection of men When these aspects of the process were removed in 2005 and 2006, 43% and 31% of awards went to women

10. Semantic priming and tenure criteria? 26 top research academic medical centers Tenure criteria from websites Scanned for �Leader� Also scanned for other Bem Sex Role Inventory male, female, neutral words Slopes of regressions for annual % tenured women x 7 years �Leader� = OR 6.0 (1.02, 35.37) for slope below median compared to those without

11. Eleven medical schools contained the word �leader� in their tenure criteria an average of 2.4 times (standard deviation = 2.2). The odds of having a slope below the median slope for all institutions was 6 times higher for schools that contain the word �leader� than for those without the word �leader� (odds ratio = 6.00, 95% confidence intervals: 1.02, 35.37; P = 0.04). Eleven medical schools contained the word �leader� in their tenure criteria an average of 2.4 times (standard deviation = 2.2). The odds of having a slope below the median slope for all institutions was 6 times higher for schools that contain the word �leader� than for those without the word �leader� (odds ratio = 6.00, 95% confidence intervals: 1.02, 35.37; P = 0.04).

12. Three Examples Semantic priming Linguistic expectancy bias Language that ignores or blames women LEB was named by a group of Dutch researchers who have done a lot of work examining how language can transmit and maintain stereotypes. LEB refers to the observation that when a behavior is consistent with a stereotype � that is gender-congruent � it is expected and individuals describe that behavior in more abstract terms than if the behavior is gender-incongruent, that is, unexpected.LEB was named by a group of Dutch researchers who have done a lot of work examining how language can transmit and maintain stereotypes. LEB refers to the observation that when a behavior is consistent with a stereotype � that is gender-congruent � it is expected and individuals describe that behavior in more abstract terms than if the behavior is gender-incongruent, that is, unexpected.

13. Linguistic Category Model Levels of linguistic abstractness: Level 1 � descriptive action verb Most concrete, specific behavior Level 2 � interpretive-action verb More abstract, class of behaviors Level 3 � State verb More abstract, emotional state Level 4 � Adjective Most abstract, generalize across events Level 1 � A shakes B�s hand Level 2 � A helps B Level 3 � A likes B Level 4 � A is helpfulLevel 1 � A shakes B�s hand Level 2 � A helps B Level 3 � A likes B Level 4 � A is helpful

14. Linguistic Expectancy Bias (LEB) Stereotype-congruent (i.e. expected) behavior is described more abstractly than stereotype-incongruent (i.e. unexpected) behavior

15. Abstract language reinforces and transmits stereotypes Subjects: 72 from University community (36 women/36 men) Subjects asked to write 4 stories about a male or female friend behaving in pos and neg stereotypically male and female way Read other�s stories Dispositional inference: Repetition likelihood Situation attribution Person attribution Situation-person attribution Rate behavior stereotypically male, female, desirable, undesirable (Likert, 1-7) Level of abstractness computed from verbs and adjectives Linguistic abstraction in the interpersonal transmission of stereotypes Repetition likelihood = estimate % of future situations same behavior Situation attribution = �to what extent is the behavior of the target due to the situation in which he or she finds himself?� Person attriubtion = �to what extent is the behavior of the target due to the situation or the person?� Situation-person = bipolar scale ranging from situation (1) to personality (100) For each story, Likert 1 (not at all) to 7 (very much) to what extent they considered the behavior displayed in the story to be stereotypically male, female, desirable, and undesirable Linguistic abstraction in the interpersonal transmission of stereotypes Repetition likelihood = estimate % of future situations same behavior Situation attribution = �to what extent is the behavior of the target due to the situation in which he or she finds himself?� Person attriubtion = �to what extent is the behavior of the target due to the situation or the person?� Situation-person = bipolar scale ranging from situation (1) to personality (100) For each story, Likert 1 (not at all) to 7 (very much) to what extent they considered the behavior displayed in the story to be stereotypically male, female, desirable, and undesirable

16. Abstract language reinforces and transmits stereotypes No effect of evaluator sex or desirability of behavior Writers� description of behavior more abstract when gender-congruent (expectant) Readers� � when behavior rated gender-congruent (expectant) ? greater dispositional inference Readers� dispositional inference ? accounted for by level of linguistic abstractness of the story Conclusion: Expected information is communicated at a higher level of abstractness than unexpected information and this effectively maintains gender stereotypes in recipients Multivariate analyses Results support the assumption that linguistic abstraction plays an important role in the interindividual transmission and maintenance of stereotypes!! Did path analysis. When both expectancy consistency and linguistic abstraction were entered into the equation simultaneously, differences in the level of abstraction were predictive of recipients dispositional inferences and relationship between the expectancy of the stories and recipients� dispositional inferences became nonsignificant. Mean level of abstraction of the stories mediated recipients; dispositional inferences. Expectancy consistent messages led to stronger dispositional inferences than expectancy-inconsistent messages and this was mediated by the level of abstraction. So: the type of story affected the mean level of abstraction; the type of story affected recipients� dispositional inferences; mean level of abstractioon affected recipients� dispositional inferenceMultivariate analyses Results support the assumption that linguistic abstraction plays an important role in the interindividual transmission and maintenance of stereotypes!! Did path analysis. When both expectancy consistency and linguistic abstraction were entered into the equation simultaneously, differences in the level of abstraction were predictive of recipients dispositional inferences and relationship between the expectancy of the stories and recipients� dispositional inferences became nonsignificant. Mean level of abstraction of the stories mediated recipients; dispositional inferences. Expectancy consistent messages led to stronger dispositional inferences than expectancy-inconsistent messages and this was mediated by the level of abstraction. So: the type of story affected the mean level of abstraction; the type of story affected recipients� dispositional inferences; mean level of abstractioon affected recipients� dispositional inference

17. Abstract language reinforces and transmits stereotypes Subjects = 72 Dutch from University community Stories stated concrete or abstract gender-congruent behaviors based on traits: Male: independent, handy, adventurous, technical Female: careful, considerate, emotional, spontaneous Subjects asked to rank target stereotypical male or female (Likert 1-7, not at all ? very much) Abstract stories led to stronger dispositional inferences regardless of content Conclusion: linguistic expectancy bias may lead to subtle, undetected forms of discrimination Traits taken from the Dutch Gender Identification Questionnaire Concrete version: Sandra is watching a dramatic movie on television. When the movie is at its lowest ebb. Sandra reaches for a tissue. She brushes away a tear from her eyes. Abstract version: Sandra is watching a dramatic movie on television. When the movie is at its lowest ebb, Sandra reaches for a tissue. She is emotional. 4 different between participants story conditions were createdTraits taken from the Dutch Gender Identification Questionnaire Concrete version: Sandra is watching a dramatic movie on television. When the movie is at its lowest ebb. Sandra reaches for a tissue. She brushes away a tear from her eyes. Abstract version: Sandra is watching a dramatic movie on television. When the movie is at its lowest ebb, Sandra reaches for a tissue. She is emotional. 4 different between participants story conditions were created

18. Subtle gatekeeping bias � letters of recommendationTrix and Psenka, Discourse & Soc 14:191 2003  312 letters of rec for medical faculty hired at large U.S. medical school Letters for women vs men: Shorter 15% vs 6% of minimal assurance 10% vs 5% with gender terms (e.g. �intelligent young lady�; �insightful woman�) 24% vs 12% doubt raisers Stereotypic adjectives: �Compassionate�, �related well�� vs �successful�, �accomplished� Fewer standout adjectives (�outstanding� �excellent�) Gatekeeping practices, including educational requirements, job interviews, and letters of recommendation, all serve to control access to particular positions and the societal benefits that thereby accrue. The higher the social status of the institution, the less public the gatekeeping. 1992-1995; 312 letters for 103 faculty positions (approx 3 letters per applicant); mostly at assist prof level but 8 assoc prof and one prof; 37 different specialties; 89 letters for women; 222 for men; one letter for a couple. Recommenders: 85% male. 96% of gatekeepers (ie those to whom the letters were addressed) were male 13% of these addressed to first name. Doubt raiser: irrelevancy, not innately negative, but the overall effect can raise doubt; e.g. she worked hard on projects that she accepted. It appears that her health and personal life are stable. An independent worker, she requires only minimal supervision.Gatekeeping practices, including educational requirements, job interviews, and letters of recommendation, all serve to control access to particular positions and the societal benefits that thereby accrue. The higher the social status of the institution, the less public the gatekeeping. 1992-1995; 312 letters for 103 faculty positions (approx 3 letters per applicant); mostly at assist prof level but 8 assoc prof and one prof; 37 different specialties; 89 letters for women; 222 for men; one letter for a couple. Recommenders: 85% male. 96% of gatekeepers (ie those to whom the letters were addressed) were male 13% of these addressed to first name. Doubt raiser: irrelevancy, not innately negative, but the overall effect can raise doubt; e.g. she worked hard on projects that she accepted. It appears that her health and personal life are stable. An independent worker, she requires only minimal supervision.

19. Semantic realms following possessive (e.g. �her training�; �his research�) More status words after hisMore status words after his

20. Distinctive semantic realms following possessive

22. NIH Extramural Nexus, January, 2007 �The disproportionate difficulty women have as Principal Investigators of large grants was obvious in the first round of the Clinical and Translational Science Awards (CTSAs) applications, where none of the applicants were women.�

23. Clinical and Translational Science Awards (CTSA) PI will be elite leader: Enormous institutional power Massive budget up to $70 million No previous performance criteria Leader of leaders: CTSA subsumes several other independent programs We predicted that it would be unlikely for women to be represented as CTSA PIs (Carnes and Bland, Acad Med, 2007); In fact, all 35 applications had male PIs.

24. Women are not people Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med, 1997 �No more than 1 drink per day in women and lighter-weight persons.� Letter to the editor with apology and promise to be more careful in JNC7. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA, 2006 �No more than 1 drink per day in women and lighter-weight persons.� Letter to the editor not accepted for publication.

25. Discussion �Our study has demonstrated that outcomes are better when hypertension in the elderly is treated with an ACE inhibitor than when it is treated with a diuretic agent�� Conclusion �Initiation of antihypertensive treatment involving ACE inhibitors in older subjects, particularly men, appears to lead to better outcomes than treatment with diuretic agents, despite similar reductions of blood pressure� Preferable �ACE-inhibitors and diuretics had comparable effects on the combined end point of cardiovascular events or death in older white women treated for hypertension. While ACE-inhibitors decreased risk of this end point for men, they also doubled the risk of fatal stroke.� Intent to mislead busy MD�s who might only read abstract? Study partially funded by Merck Sharp & Dohme, two of the investigators receive grants and consulting fees from MS&D and one of the authors is employed by MS&D. All authors appear to be men. Discussion �Our study has demonstrated that outcomes are better when hypertension in the elderly is treated with an ACE inhibitor than when it is treated with a diuretic agent�� Conclusion �Initiation of antihypertensive treatment involving ACE inhibitors in older subjects, particularly men, appears to lead to better outcomes than treatment with diuretic agents, despite similar reductions of blood pressure� Preferable �ACE-inhibitors and diuretics had comparable effects on the combined end point of cardiovascular events or death in older white women treated for hypertension. While ACE-inhibitors decreased risk of this end point for men, they also doubled the risk of fatal stroke.� Intent to mislead busy MD�s who might only read abstract? Study partially funded by Merck Sharp & Dohme, two of the investigators receive grants and consulting fees from MS&D and one of the authors is employed by MS&D. All authors appear to be men.

26. Inadequate compliance with NIH guidelines to include women in clinical trials NIH Revitalization Act of 1993 � NIH required to include women; other fed agencies followed 9 high impact medical journals in 2004 46 studies, not sex-specific 70% enrolled = 30% women 40 (87%) did not report outcomes by sex or include sex as a covariate in modeling None acknowledged limits of generalizability (including 7 studies with <20% women)

27. Recommendations Acknowledge that we all have biases and assumptions Examine language at gatekeeping junctures for evidence of semantic priming and linguistic expectancy bias Describe desired behaviors in specific, concrete terms to avoid transmitting stereotypes Continue to raise awareness of the fact that: �fixing the women� is not enough to achieve gender equity it is not good science to exclude women or to fail to note the limits of generalizability and it is potentially harmful to women�s health

30. Summary 2004: <20 2005 >26% applicants Reviewers: 6% vs 44%2004: <20 2005 >26% applicants Reviewers: 6% vs 44%

31. Free language production Passing on a received story Generating own story