Some of the reasons in the thought bubbles represent subjective beliefs, and some represent practical constraints on material resources, such as finances and time. In our own examination of reasons behind ‘why women say no’, we identified strongly with constraints on time. Although the ally’s thoughts indicate a genuine desire to recognize her expertise, accompanied by acknowledgement of the need to sponsor women, he is not considering the significant material constraints that limit her ability to accept the invitation. Recognizing a need to illuminate these barriers and build capacity amongst allies, we looked to the literature to determine if there is evidence that, compared to men, women have less time for career advancement opportunities, such as research and leadership. To deepen our understanding of this phenomenon, we then sought to explore why women might have less time for research and leadership, compared to men. And particularly, in cultures where gender equality is the norm, how are gender disparities maintained? Finally, we offer practical guidance on how allies can help, going beyond simply extending more invitations to women to address the psychological and material barriers that undermine women’s ability to say “yes”.

Methods

Our critical review draws on diverse literatures to seek out more nuanced explanations for why women say no, or, more specifically, why they cannot say yes, to opportunities for career advancement. When conducting critical reviews, researchers do not seek a comprehensive accounting of everything that has been said on a topic; rather, they draw on expertise within the team and consult with experts outside the team to select perspectives that best inform their questions and that have the greatest potential to shift their field’s thinking on their topic.47
Our team is comprised of three academics who identify as women and are active in medical education. We have worked and trained at different institutions in Canada, trained in different disciplines, and hold different family statuses, racial identifications, and career stages. Dr. Monteiro is a mid-career researcher, trained in cognitive psychology – a perspective that greatly informed our discussions. She identifies as a person of colour and parent to young adults. Dr. Chan is a practicing academic physician in emergency medicine. She is an active health professions’ education researcher who identifies as being in her mid-career. She has also held many leadership positions at her institution and at a national level. She identifies as a person of colour and her observations and experiences during her climb through the ranks of leadership greatly impacted our conversations. Dr. Kahlke is an early career researcher with a young family. She holds a PhD in Education, and her sociocultural perspective helped to balance and frame our focus on literatures from cognitive psychology. Spurred by an interest in the anecdote presented above, we began this review by consulting our own lived experience of the gender gap and discussed the reasons that women might say “no” when faced with an opportunity that might be seen as beneficial to our career advancement. Differences in our intersectional identities were critical in generating robust discussions that resulted in identification of myriad reasons why different women might say no. Our different disciplinary perspectives also informed our understanding of the problem, and the literatures we consulted.
We then turned to the literature to explore evidence for our shared belief that women have less time for these “opportunities” because they have greater time demands in other areas. We asked: do women have less time for career advancement opportunities, such as speaking engagements, research, and leadership? We drew on robust literatures from Psychology (cognitive, industrial, and educational), Sociology, Health Professions Education, and Business to confirm that competing pressures on women’s time negatively impacts their decisions about career advancement opportunities. This evidence is described in detail in the first section of the results below.
We then turned to these same literatures in search of potential explanations for why this gendered imbalance in available time for career advancement has proved so persistent, asking: why might women have less time for career advancement opportunities? And how are these disparities maintained? Finally, in effort to recommend novel and evidence-based solutions to remedy the gender gap in our field, we asked: how can allies help? To address these questions, we engaged in an iterative cycle of refining the problem through group discussion, identifying new search directions, and returning to these literatures. In this way, our searches and analyses were intertwined. For example, some search directions proved less relevant to our evolving research questions and were dropped from our analysis. In keeping with critical review methodologies, other perspectives were determined to be particularly fruitful, such as stereotype theory from cognitive psychology, which offered insight into the mechanisms that contribute to the persistence of the gender gap, and cause women to say ‘no.’ Thus stereotypes literature forms the backbone of our findings related to these three questions.

Results

Do women have less time for career advancement opportunities, such as research and leadership?

In addition to evidence that women receive less recognition for their research and fewer invitations to collaborate in research and engage in leadership activities, our analysis of the literature from psychology, sociology, business and medicine supports our argument that women say no to these opportunities because they disproportionately take on other tasks that are not as well recognized, specifically those related to caretaking in their personal lives or supporting others at work.11,37,48 Studies showing differences in well-compensated clinical hours between men and women are mirror images of studies showing differences between men and women in time spent on supporting others. 49,50 For example, women are more likely to sacrifice work responsibilities to care for children/family; globally, 75% of unpaid work is done by women, including child and elder care.4,51 Women are more likely to spend their time acting as an academic mentor49, a pattern that extends even to ‘ghost advising’; or serving as an academic mentor without explicit recognition. 52 These mentoring and caretaking activities are critical to the functioning of academia and society more broadly, but they come at great cost to women. The result of this imbalance in labor is clear - women are slower to advance their careers because they have less time to spend on well recognized and compensated research and self-promotion/tenure seeking activities.49 On average, women simply don’t have the same amount of time to commit to applying for and acting in leadership positions, preparing for keynotes, or engaging in other time-consuming but high profile academic activities. Without careful consideration for how to distribute these commitments and recognition of these contributions equitably, women may continue to say no to the very opportunities that can close the gap.

Why might women have less time for research and leadership?

It is crystal clear that the problem is not women’s capability; studies consistently demonstrate equal cognitive capacity of men and women in all types of academic, managerial, mentorship and leadership activities.4,34 Indeed, several studies have highlighted benefits of including women in leadership.53 Our analysis of the literature also suggests a reason why these disparities persist: women spend more time on tasks that help others because of society’s expectation of them and of their male colleagues. In part, women help others more because men are not expected to help. In other words, women and men continue to perform stereotyped roles.11,18,20,33,37,48,54 Historically, women in most societies have been expected to play a nurturing family- and community-oriented role while men develop identities outside the home through their career or talents.4,33 These expectations persist today. For example, in personal or home contexts, women are expected to, and do, manage reminders and to-do lists, while men contribute less to these activities, and experience less societal pressure to do so.54 Socialization into these domestic roles reinforces expectations that women will commit their time and energy to the benefit of the community over individual career advancement.54
Why should these outdated notions have such a powerful hold over our behavior today? Many believe, in fact, that these expectations no longer hold true and should not drive behavior. 44,55 And although gender roles have certainly evolved, with more women working outside the home in diverse careers, there remain powerful gender stereotypes rooted in these traditional expectations; the stereotype of women as nurturing and less suited for leadership positions (thought to require assertiveness) is even stronger today than it used to be.34,55,56 Stereotypes, which are learned from birth and entrenched as early as 6 years of age, form societal expectations and limitations around how men and women should or should notbehave.9,57 For example, stereotypes characterize female academic clinicians as more nurturing, while men are characterized as brilliant assertive leaders. 9,58,59As a consequence, women are ushered into underrecognized supportive roles that are often disguised as opportunities, but limit opportunity for further advancement; these decisions are often reactions to the stereotype that men have the required characteristics for leadership.9 For example, women are often invited to deliver Grand Rounds, which have local impact, but are overlooked for keynote speaker engagements at international conferences.9,60–62 Conversely, women may avoid higher profile or highly competitive situations, such as vying for keynote speaker engagements or senior leadership positions, because of their self-perceived lack of assertiveness, a perception which may be confirmed by their mentors.15

How are these disparities maintained?

Breaking with such firmly entrenched stereotypes has consequences.60,62 These consequences can be perpetrated by others in a social environment (e.g. criticism ) or through self-sabotage (e.g. self-doubt). Social consequences generally occur because women are rarely expected in high profile roles and they are burdened with a greater need to prove themselves and demonstrate their expertise. Women often face social consequences such as doubt and criticism when they venture into leadership positions, which are seen as stereotypically male.63,64 For example, colleagues and search committees cast doubt on women’s qualifications when they apply for senior leadership positions because women do not “look like leaders”.44,57,65 Women leaders are often criticized for their leadership styles, which may not fit the stereotypical male style. 44,66 This puts women in positions taking on the extra labor of convincing search committees and co-workers that they are assertive enough, or ‘male,’ enough.62,63,63,67,68 Conversely, women are expected to have better interpersonal skills compared to men, and are held to a different standard: whether rated as a teacher, clinician, scientist or leader, women are criticized more harshly if their interpersonal skills are perceived as weak, while men are not.57,69
Myriad other findings contribute to a picture that explains why women often say no: women leaders or keynotes may be dismissed as a token representative, with more credit given to their male colleagues (ref; Matilda effect; invisible women). Women also report feeling a lack of support and fear of reprisal from co-workers if they take a job others see as clearly intended for a man.70 Women are encouraged to step up and lean in, but there is little recognition for the risks they take and heightened barriers they face when doing so.48 Realistically, who would want the hassle of ‘advancing’ one’s career by competing for a new role, with unlikely success and high professional and social consequences?60,71 And when in doubt regarding the potential outcomes of trying something new, people often revert to the familiar. 72–76
Women have developed several strategies for navigating these challenges covertly, while still trying to achieve their personal goals. However, these strategies are not designed to correct stereotypes. For example, a woman might head off negative reactions to her advancement from colleagues by suggesting she is only taking someone else’s (typically a male mentor’s) advice.33,34 She might also emphasize her femininity so that her more ‘masculine’ leadership style is not appraised too critically.33,34,77,78 By contrast, Glick et al. demonstrated that when women highlight characteristics and accomplishments often perceived as ‘masculine’, they improved their ranking in competition for leadership positions, compared to those who highlighted more ‘feminine’ accomplishments. 67Influential masculine characteristics included statements about stereotypical male hobbies and interests. However, giving one’s CV a masculine makeover is not an appropriate solution as this still prioritizes the male stereotypes as the preferred model for leadership, rather than challenging this problematic hierarchy. Similarly, embracing the feminine stereotype is equally harmful. Both adaptations fail to address the inequities in how we value activities critical to academia and society, and the systems that prevent women from progressing in their academic careers.
Other studies suggest that women may try to “fit in” to systems that value stereotypically masculine traits by self-silencing, or choosing not to take on inequity.4,33,77 Rather than altering the system, these strategies rely on women’s acquiescence to the status quo. In another related strategy, women may disengage from mainstream and stereotypically masculine spaces by seeking the safety of microcultures to avoid constant criticism or a feeling that they don’t fit the mold.4,34,77 Microcultures can create safe spaces for underrepresented groups, but can also serve to diminish much needed visibility and equitable access to mainstream spaces and opportunities.34 Finally, to offset the pressures created by societal expectations, women occupying leadership or other spaces of power may prioritize work life balance more than their male counterparts. These decisions may help them navigate the pressures they face when they choose not to align with prescriptive stereotypes. However, those decisions may also hinder further promotion, as women again sacrifice time that they could use to advance better rewarded career metrics in a traditional merit or reward systems.
Alongside the external pressures and consequences involved in challenging stereotypes, there is a self-sabotaging phenomenon described in the psychology literature as stereotype threat. 79For example, a common stereotype of women, (noted in published work since the 1990s but present in academic discourse for decades prior to that) is a belief that women are weaker at learning and mastering concepts in mathematics.57,80,81 When placed in a competitive context requiring math skills, women often perform poorly, or choose not to compete at all.81 This phenomenon is not related to ability, as it occurs even for women with exceptional aptitude and knowledge of the domain.57,80,81 A more modern conceptualization of this phenomenon is imposter syndrome .82,83 All individuals who identify with a negative stereotype are susceptible to the phenomenon of stereotype threat, with the primary explanation being a sub-conscious drop in confidence and performance. The evidence suggests that knowledge and fear of being compared to a negative stereotype causes people to lose confidence and inadvertently confirm the stereotype. Decades of research on stereotype threat reveal its impact in domains such as sports84, leadership 85,86, and communication skills.87 For example, women, who are aware of the negative stereotype regarding women and some sports, may opt out of competitive sports activities altogether. Men are not immune88; in one study, men were observed to perform in ways that were less empathetic, or caring, when primed with the stereotype that women are more nurturing than men, compared to men who were not primed with this stereotype.89 Even as women venture into non-traditional roles, the phenomenon of stereotype threat may serve to support harmful stereotypes.90,91

How can allies help?

Allies, whether men or women, need support and guidance to be effective. Recommendations for addressing the impact of stereotypes and stereotype threat require specific and concrete actions, not vague guidelines.4,34 Critically allies need support to help them and others understand the mechanisms that will lead toequity between genders, which are very different from initiatives that recognize equality between genders; believing that all genders are equal is not enough to reach gender equity when there are real material barriers hindering women’s advancement. Allies are critical in helping amplify and recognize the contributions and perspectives of women and underrepresented groups.
The key recommendations from the literature:
  1. Recognize, consult, and support women when they are uniquely positioned - recognize that an invitation to apply may not be enough to counterbalance disproportionate negative fallout that women often experience,4
  2. Create supportive microcultures (that actually impact mainstream),4
  3. Set expectations & realign merit systems,92
  4. Actively seek out women for more traditionally male roles,55
  5. Actively seek out men for more traditionally female roles.55
Our Supplemental Digital Content (Appendix 1) outlines some ways that people in various leadership positions can support women and other underrepresented groups. In hoping to close the knowing-doing gap, we have grouped the suggestions by leadership roles that are common to the academic clinical environment. We then follow each recommendation with a worked example, or continuance of the vignette, to demonstrate how allies can take action.