Sexism vs cultural imperialism
As I was getting ready for bed last night a friend shared a tweet that immediately caught my attention.
The tweet was of a paper that has just been published online, titled "Does physician gender have a significant impact on first-pass success rate of emergency endotracheal intubation?" and showed the abstract which began,
I then took a deep breath and asked myself why a respected journal, The American Journal of Emergency Medicine, would publish such idiocy. Maybe there was something else going on. The best way to find out is to read the paper so I got a copy and started reading. The first thing that struck me was the author affiliations - both are associated with hospitals in Seoul, South Korea. The second author had an online profile, he is a Clinical Professor of Emergency Medicine. I couldn't find the first author anywhere which made me think they are probably quite early in their career. The subject matter wasn't something I could imagine a male early career researcher being interested in so figured they are probably female (not knowing Korean names I couldn't work out if the name was feminine or masculine).
This immediately gave it a different slant. Sexism is a massive problem in Korea. Gender roles are heavily enforced and gender inequality is among the worst in the world. At the beginning of this year its neighbour Japan announced that women have been outperforming men in medical entrance exams since they stopped rigging them to prevent women from getting through. Japan has the lowest percentage of female doctors in the OECD at 21.1% and Korea is only just above them at 22.1%. It hardly seems a stretch, therefore, to assume that female Korean doctors experience persistent sexism in their work. And here we have a doctor at the beginning of her career trying to tackle that sexism by providing incontrovertible evidence that she and her female colleagues are every bit as capable of performing a life-saving procedure as her male colleagues.
Why did they chose intubation? I can't say for sure but the paper gives some hints.
So we have a paper being written in a non-first language about a topic that gets very little attention in Korea but blights the careers of many female professionals. That's incredibly brave in my mind. The paper has flaws - every paper has flaws - and one flaw is that doesn't put the problem of sexism in medicine into a context, and that's something that the reviewers and editors should have picked up on. But the research is sound. They spent 3 years (2013-2016) collecting data and it's taken until now to get it analysed and through peer review to be published. This isn't something cobbled together one night over beers.
It finally gets published online, gets spotted by someone on Twitter and all hell breaks loose. No matter the cries of people who try to provide context,
it's apparently been decided that the paper is sexism at its worst and must be stopped.
So now we have a woman at the start of her career who was probably incredibly proud that she’d not only got a paper published, but in an international journal and on a subject that matters to her and her colleagues. Her paper might even reduce the sexism they face every time they perform an intubation. And she’s worked with an established male researcher who has used his position of authority to help guide this paper to publication because he’s aware that the sexism in Korea is rife and needs challenging. These are two people doing good work that should be celebrated and applauded.
But instead we have this,
That's right. They're going to withdraw the paper.
I can't tell you how angry this makes me. Feminists who support equality and want women to enter into traditionally-male fields have forced a woman at the beginning of her career to withdraw a paper from publication because it wasn't framed the way they wanted. This paper could have been the ammunition female physicians around Korea needed to shut their sexist colleagues up when they attempted to perform an intubation but instead they'll have nothing.
It's all very well to say that asking these sorts of questions assumes that women are inherently worse than men but the problem is men assume that already. I wish we didn't need this sort of research, and part of me fears that no matter the evidence there'll always be some who'll believe women are worse than men, but until most men around the world accept that the lack of a penis doesn't mean you can't perform medical procedures research of this type is needed as ammunition against them.
This case is a perfect example of not everything being about you. Just because it's published in an American journal doesn't mean the primary audience is American and to impose American moral frames is cultural imperialism. No one has disputed the evidence, only the way it was framed. Whilst it could have been worded better from a Western perspective, that doesn’t invalidate the evidence. It also ignores the fact that this paper was aimed at those in Korea and the wider Asian medical community for whom sexist assumptions about the abilities of women are ingrained. The publication in a US journal is to add prestige to the paper so that the results are seen as worthy of consideration. It probably wouldn't have made a seismic difference but even a small improvement is a start. And now it won't even do that because the authors have been forced into withdrawing it by people who misunderstood its aims and intentions. This is not a win for feminism. This is not a win for academic rigour. It's a loss for all who aim to improve the position of women around the world and I go to bed tonight feeling angry, sad and ashamed.
ADDENDUM
It's been brought to my attention by Andrew Althouse that the noninferiority test that was used in this paper was not, as some readers assumed, a dig at the presumed inferiority of women, but is a standard statistical test used in clinical medicine. If you google the term you'll find lots of papers discussing its use. The noninferiority test has a null hypothesis that the new method is inferior (so in this case, that women are less good at intubating than men) and the research hypothesis is that the new method is equal to or better than previous ones (so in this case, that women are as good as or better than men at intubating). If you're trying to prove that something is better than something else it's the best statistical test to use.
 |
| https://twitter.com/sbattrawden/status/1143465003409915905 |
The tweet was of a paper that has just been published online, titled "Does physician gender have a significant impact on first-pass success rate of emergency endotracheal intubation?" and showed the abstract which began,
It is unknown whether female physicians can perform equivalently to male physicians with respect to emergency procedures.Understandably, this got the backs up of a lot of people, myself included. Who on earth thinks that's a valid question to be researching in this day and age? Are we really still having to battle assumptions of female inferiority when it comes to things like this? Who on earth gave this ethics approval, let alone got it though peer review?
I then took a deep breath and asked myself why a respected journal, The American Journal of Emergency Medicine, would publish such idiocy. Maybe there was something else going on. The best way to find out is to read the paper so I got a copy and started reading. The first thing that struck me was the author affiliations - both are associated with hospitals in Seoul, South Korea. The second author had an online profile, he is a Clinical Professor of Emergency Medicine. I couldn't find the first author anywhere which made me think they are probably quite early in their career. The subject matter wasn't something I could imagine a male early career researcher being interested in so figured they are probably female (not knowing Korean names I couldn't work out if the name was feminine or masculine).
This immediately gave it a different slant. Sexism is a massive problem in Korea. Gender roles are heavily enforced and gender inequality is among the worst in the world. At the beginning of this year its neighbour Japan announced that women have been outperforming men in medical entrance exams since they stopped rigging them to prevent women from getting through. Japan has the lowest percentage of female doctors in the OECD at 21.1% and Korea is only just above them at 22.1%. It hardly seems a stretch, therefore, to assume that female Korean doctors experience persistent sexism in their work. And here we have a doctor at the beginning of her career trying to tackle that sexism by providing incontrovertible evidence that she and her female colleagues are every bit as capable of performing a life-saving procedure as her male colleagues.
Why did they chose intubation? I can't say for sure but the paper gives some hints.
We hypothesized that... while successful endotracheal intubation may require both skill and strength, the importance of correct technique far outweighs physical strength.In other words, female doctors are being told they can't be any good at intubation because they don't have the requisite strength, and the authors of this paper are aiming to test this assumption.
So we have a paper being written in a non-first language about a topic that gets very little attention in Korea but blights the careers of many female professionals. That's incredibly brave in my mind. The paper has flaws - every paper has flaws - and one flaw is that doesn't put the problem of sexism in medicine into a context, and that's something that the reviewers and editors should have picked up on. But the research is sound. They spent 3 years (2013-2016) collecting data and it's taken until now to get it analysed and through peer review to be published. This isn't something cobbled together one night over beers.
It finally gets published online, gets spotted by someone on Twitter and all hell breaks loose. No matter the cries of people who try to provide context,
 |
| https://twitter.com/medicaldork/status/1143512215774875648?s=19 |
it's apparently been decided that the paper is sexism at its worst and must be stopped.
So now we have a woman at the start of her career who was probably incredibly proud that she’d not only got a paper published, but in an international journal and on a subject that matters to her and her colleagues. Her paper might even reduce the sexism they face every time they perform an intubation. And she’s worked with an established male researcher who has used his position of authority to help guide this paper to publication because he’s aware that the sexism in Korea is rife and needs challenging. These are two people doing good work that should be celebrated and applauded.
But instead we have this,
 |
| https://twitter.com/joonghee_emdoc/status/1143927857174831104?s=19 |
That's right. They're going to withdraw the paper.
I can't tell you how angry this makes me. Feminists who support equality and want women to enter into traditionally-male fields have forced a woman at the beginning of her career to withdraw a paper from publication because it wasn't framed the way they wanted. This paper could have been the ammunition female physicians around Korea needed to shut their sexist colleagues up when they attempted to perform an intubation but instead they'll have nothing.
It's all very well to say that asking these sorts of questions assumes that women are inherently worse than men but the problem is men assume that already. I wish we didn't need this sort of research, and part of me fears that no matter the evidence there'll always be some who'll believe women are worse than men, but until most men around the world accept that the lack of a penis doesn't mean you can't perform medical procedures research of this type is needed as ammunition against them.
This case is a perfect example of not everything being about you. Just because it's published in an American journal doesn't mean the primary audience is American and to impose American moral frames is cultural imperialism. No one has disputed the evidence, only the way it was framed. Whilst it could have been worded better from a Western perspective, that doesn’t invalidate the evidence. It also ignores the fact that this paper was aimed at those in Korea and the wider Asian medical community for whom sexist assumptions about the abilities of women are ingrained. The publication in a US journal is to add prestige to the paper so that the results are seen as worthy of consideration. It probably wouldn't have made a seismic difference but even a small improvement is a start. And now it won't even do that because the authors have been forced into withdrawing it by people who misunderstood its aims and intentions. This is not a win for feminism. This is not a win for academic rigour. It's a loss for all who aim to improve the position of women around the world and I go to bed tonight feeling angry, sad and ashamed.
ADDENDUM
It's been brought to my attention by Andrew Althouse that the noninferiority test that was used in this paper was not, as some readers assumed, a dig at the presumed inferiority of women, but is a standard statistical test used in clinical medicine. If you google the term you'll find lots of papers discussing its use. The noninferiority test has a null hypothesis that the new method is inferior (so in this case, that women are less good at intubating than men) and the research hypothesis is that the new method is equal to or better than previous ones (so in this case, that women are as good as or better than men at intubating). If you're trying to prove that something is better than something else it's the best statistical test to use.
 |
| source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3019319/ |
Comments
The use of the "non-inferiority" test and the phrase "not inferior" seems to be one of the reasons this paper has been received with such hostility.
An "equivalence" test sounds less inflammatory (I wonder in an alternate world if that word had been used, what the reaction would have been) but it's actually a worse choice of statistical test for the female physicians in the study, given the objective - it doesn't allow for the possibility that the female physicians would outperform the male physicians!
The objective of this research was to test whether female physicians were equal to or better than male physicians at a given procedure. It's a textbook situation for a non-inferiority test, and it was described correctly by the authors. I can appreciate that technical statistics language may sound insensitive, but it's literally the technically correct name for the test that goes with what the authors were attempting to show.
One of my main concerns was how AJEM seemed to have handled the article from a publication process. Gender equity is a very sensitive subject. Did they recognize in advance the article could be misunderstood in a global 2019 audience? If so, what steps did they take?
AJEM could have mitigated some of the negative social media response if they had included some statement or accompanying editorial.
It will be interesting to see if an how AJEM addresses the situation now.