Gender Equality in Healthcare Leadership: A Narrative Review of the Literature

1. Introduction

In 2019, the World Health Organization (WHO) disclosed that women still strive to cover a significant role in scientific fields as they constitute only 12% of the members of national scientific academies at the global level. Although they make for 70% of the healthcare labor force, only 25% have secured leadership roles in healthcare [1]. Gender-based obstacles and numerous inequalities interfere with women’s capability to fill leadership positions, restrict diverse viewpoints, and prevent the inclusion of women’s evaluations in the decision-making. Female leaders approve investments in educational and health fields more frequently than male leaders and pay more attention on the necessities of women, minors, and marginalized communities [1].

This issue emphasizes the urgent necessity for more female leaders in healthcare, since their unique perspectives and expertise can significantly enhance decision-making processes.

1.1. The Leader and Key Qualities

Brown describes a leader as “a person who can influence others in the group” [2]. Effective leaders are open and sincere when communicating and motivate their teams by constantly recalling mutual goals and expectations. True leadership entails not only accomplishing outstanding professional outcomes, but also encouraging high morale, determination, and engagement among team members [3]. This emotional side of the leader is both the original essence and the fundamental element of leadership. In any time and culture, leaders offer protection and security in uncertain and dangerous periods because of their enthusiastic and collegial approach, otherwise, resentment and anxiety can emerge and lead to disorientation. A thorough analysis of operative working groups shows that leaders play a crucial role in determining shared emotions [2].

Brown also defines leadership as “a form of influence marked by the ability to elicit voluntary consensus and motivated acceptance from individuals towards group or organizational objectives.” This definition stresses the relevance of persuasion and influence. Modern leadership theories point out the quality of the relationship between leaders and followers, and underline the importance of mutual loyalty and trust, which generates greater employee satisfaction and performance [4].

1.2. Leadership and Gender

The ’great man’ leadership theory has consistently credited achievements to exceptional men and has by definition excluded women. This concept is nowadays perceived as old-fashioned and myopic, however, the persistent view that men are more suited to leadership roles than women remains a problem. In many professional contexts, women face the so-called ’glass ceiling’, a term that refers to obstacles and barriers that prevent their admission to positions of greater responsibility.[5] Also, they encounter the ’glass cliff’, where they are often selected for higher-risk projects, which expose them to criticism if the project fails. Further, women can be less motivated to pursue high-leadership positions since they face family and caregiving responsibilities and are affected by negative stereotypes associated with female leadership [6]. Gender integration is critical as it results in a positive impact on healthcare and development sectors. Academic literature identified several reasons for the gender disparity in anesthesiology leadership and faculty positions. This disparity is due to unsupportive work environments, lack of mentorship, personal choices, childcare responsibilities, and active discrimination against women [7]. In-depth interviews were administered to 18 medical doctors working in academia in 13 different institutions: 40% is convinced that gender discrimination is the primary factor that prevents academic career advancement [8]. Also, women are less likely to receive credit for their academic achievements than men, especially in the assignment of funding and grants. Indeed, women had to publish three additional articles on high-impact factor journals or twenty additional articles on well-known journals in their fields. Women are also often discriminated in evaluations and hiring processes. As an example, recommendation letters for women are often more concise and concentrate on gendered attributes rather than professional achievements. Although equally qualified, women are perceived as less competent in different academic fields [4].

Gender-based conventional perceptions about leadership styles also generate obstacles [9]. Men in most cases display a transactional leadership focused on hierarchy, sanctions, and negotiation of benefits, and favor an autocratic style based on assertiveness. Conversely, women tend towards transformational leadership, which can reshape the value framework and the motivation of team members through persuasion and attention to individual needs. Women are inclined to stress empathy, communication, and team cooperation [10]. Women favor the development of individual potential, embrace team members, take risks, transform project objectives into team efforts, and pay attention to the well-being of their members. In this way, they earn respect, gain personal recognition, reduce social distance, and strengthen the perception of accessibility to decision-making positions. These attributes encourage a sense of belonging and well-being in organizations and women leaders are perceived as respected and approachable [11].

Table 1 shows the difference between female and male leadership.

1.3. Study Objectives

This paper accomplishes a complete literature review to examine female leadership by addressing three research questions:

• What differences emerge between female and male leadership styles?
• What are the stereotypes in this context, and why are women sometimes negatively labeled as “alpha”?
• What obstacles and barriers persist in achieving leadership positions, and what actions can address these challenges?

2. Materials and Methods

As a result of a literature peer review accomplished on Pubmed, using specific search strings listed below, an analysis was carried out on the main articles comprising of answers to the research questions formulated above; the questions were developed employing the PICO model:

• Population (P): Women
• Intervention (I): Overcoming stereotypes and biases
• Comparison (C): Men
• Outcome (O): Promoting female leadership

The query research used, with keywords, both free and MeSH, is:

(Female leadership) AND ((bias) OR (stereotype) OR (academic) OR (gender))

2.1. Inclusion and Exclusion Criteria

Inclusion criteria are:

1)

presence in a peer reviewed journal in Pubmed database

2)

only “article” and “review” type of publication is admitted

3)

publication data in the last 5 years (2019-2024)

4)

free full text availability

5)

publications written in English

The article not cross-matched with inclusion criteria are excluded.

3. Results

Applying the filters, 967 articles were identified. The “last 5 years” filter retrieved 397 articles. The “free full-text” collected 144 articles. After screening titles (every author analyzed 9 articles, in alphabetic order), remains 126 articles. Screening abstracts with the some methodology, 80 article were selected. The lecture of full text (in the same way) excluded 62 articles. 18 papers remained. These articles were employed for the qualitative synthesis, as shown in the table below.

Table 2. Qualitative Summary of Reviewed Articles.

AUTHOR	TITLE	JOURNAL	YEAR OF PUBLICATION	MAIN FINDINGS
Cardel M. I. Dhurandhar E. Yarar Fisher C. et al.	Turning Chutes into Ladders for Women Faculty: A Review and Roadmap for Equity in Academia [12]	J Womens Health	2020 May	Achieving equity in an academic world dominated by prejudice and stereotypes is a complex but achievable challenge.
Sumra MK.	Masculinity, femininity, and leadership: Taking a closer look at the alpha female [13]	Plos One	2019	The personality traits of women leaders.
Victoria T. Kline-Fath B.	Women in pediatric radiology: a call for gender equity [14]	Pediatr Radiol	2022	Progress towards equity between women and men emerges compared to decades ago.
Blaszczak W. Ahmed A. Leithner K. et al.	Outlook of women in science: an interview with our author [15]	Mol Oncol	2022 Mar	The experiences of several female scientists regarding gender diversity encourage women to take up leadership positions.
Kubik-Huch R.A. Vilgrain V. Krestin G. P. et al.	Women in radiology: gender diversity is not a metric-it is a tool for excellence [16]	Eur Radiol	2020 Mar	Gender diversity improves organisational effectiveness.
Ford Winkle A. Telzak B. Shaw J.	The Role of Gender in Careers in Medicine: a Systematic Review and and Thematic Synthesis of Qualitative Literature [17]	J Gen Intern Med	2021 Aug	Despite significant representation by women, assumptions based on outdated stereotypes associated with men still dominate medicine.
Critchley J. Schwarz M. Baruah R.	The female medical workforce [18]	Anaesthia	2021 Apr	The reasons for the under-representation of women in some medical specialities and medical leadership positions are multifactorial, but gender stereotypes and biases can play a significant role.
Chung E. El-Harakeh A. Weinberg J L. et al.	A Scoping Review on Resources, Tools, and Programs to Support Women’s Leadership in Global Health: What Is Available, What Works, and How Do We Know? [1]	Ann Glob Health	2023 Apr	Including appropriate and inclusive goals and needs assessments is a pathway to begin creating effective and equitable interventions to increase women’s leadership in global health and overcome barriers that limit women leaders in global health.
Gurung D. Sangraula M. Subba P.	Gender inequality in the global mental health research workforce: a research authorship scoping review and qualitative study in Nepal [8]	BMJ Glob Health	2021 Dec	Structural barriers intensify the gender gap in health research.
Hastie M. J. Lee A. Siddiqui S.	Misconceptions about women in leadership in academic medicine [19]	Can J Anaesth	2023 May	Institutions must create supportive environments and fair opportunities.
Bosco L. Lorello G. R. Flexman A. M.	Women in anaesthesia: a scoping review [11]	Br J Anaesth	2020 Mar	Gender discrimination is the main factor responsible for academic career advancement.
Gonzalez L. S. Fahy B. G. Lien C. A.	Gender distribution in United States anaesthesiology residency programme directors: trends and implications [20]	Br J Anaesth	2020 Mar	Recruiting more women in anaesthesiology, together with interventions to recruit female academic faculty members, reduces the effects of gender bias on recruitment, promotion, and departmental culture.
Ryan M. K. Morgenroth T.	Why We Should Stop Trying to Fix Women: How Context Shapes and Constrains Women’s Career Trajectories [21]	Annu Rev Psychol	2024 Jan	The most successful strategy would encourage organisations to give all women something extra to support them.
Tricco A. C. Nincic V.Darvesh N. et al.	Global evidence of gender equity in academic health research: a scoping review [6]	BMJ Open	2023 Feb	There is a need to identify interventions to promote gender equality at all levels of organisations.
Caywood K. Darmstadt G. L.	Gender mainstreaming at 25 years Toward an inclusive, collaborative, and structured research agenda [7]	J Glob Health	2024 Jan	Inclusive, collaborative and structured research can better harness academia to assist practitioners and advocates in realising the relevance of gender mainstreaming and the potential for impact in the health and development sectors.
Schwartz R. Williams M. F. Feldman M. D.	Does Sponsorship Promote Equity in Career Advancement in Academic Medicine? [5]	J Gen Intern Med	2024 Feb	Leaders must strive to create a culture of sponsorship relevant to career advancement in medicine.
Khounsarian F. Abu-Omar A. Aida Emara A. et al.	A trend, analysis, and solution on women’s representation in diagnostic radiology in North America a narrative review [22]	Clin Imaging	2024 May	A more diverse and representative discipline of radiology contributes to better patient care and satisfaction.
Bellini M. I. Adair A. Fotopoulou C.	Changing the norm towards gender equity in surgery the women in surgery working group of the Association of Surgeons of Great Britain and Ireland’s perspective. [3]	J R Soc Med	2019 Aug	A diverse and inclusive environment should be favoured.

Table 2. Qualitative Summary of Reviewed Articles.

AUTHOR	TITLE	JOURNAL	YEAR OF PUBLICATION	MAIN FINDINGS
Cardel M. I. Dhurandhar E. Yarar Fisher C. et al.	Turning Chutes into Ladders for Women Faculty: A Review and Roadmap for Equity in Academia [12]	J Womens Health	2020 May	Achieving equity in an academic world dominated by prejudice and stereotypes is a complex but achievable challenge.
Sumra MK.	Masculinity, femininity, and leadership: Taking a closer look at the alpha female [13]	Plos One	2019	The personality traits of women leaders.
Victoria T. Kline-Fath B.	Women in pediatric radiology: a call for gender equity [14]	Pediatr Radiol	2022	Progress towards equity between women and men emerges compared to decades ago.
Blaszczak W. Ahmed A. Leithner K. et al.	Outlook of women in science: an interview with our author [15]	Mol Oncol	2022 Mar	The experiences of several female scientists regarding gender diversity encourage women to take up leadership positions.
Kubik-Huch R.A. Vilgrain V. Krestin G. P. et al.	Women in radiology: gender diversity is not a metric-it is a tool for excellence [16]	Eur Radiol	2020 Mar	Gender diversity improves organisational effectiveness.
Ford Winkle A. Telzak B. Shaw J.	The Role of Gender in Careers in Medicine: a Systematic Review and and Thematic Synthesis of Qualitative Literature [17]	J Gen Intern Med	2021 Aug	Despite significant representation by women, assumptions based on outdated stereotypes associated with men still dominate medicine.
Critchley J. Schwarz M. Baruah R.	The female medical workforce [18]	Anaesthia	2021 Apr	The reasons for the under-representation of women in some medical specialities and medical leadership positions are multifactorial, but gender stereotypes and biases can play a significant role.
Chung E. El-Harakeh A. Weinberg J L. et al.	A Scoping Review on Resources, Tools, and Programs to Support Women’s Leadership in Global Health: What Is Available, What Works, and How Do We Know? [1]	Ann Glob Health	2023 Apr	Including appropriate and inclusive goals and needs assessments is a pathway to begin creating effective and equitable interventions to increase women’s leadership in global health and overcome barriers that limit women leaders in global health.
Gurung D. Sangraula M. Subba P.	Gender inequality in the global mental health research workforce: a research authorship scoping review and qualitative study in Nepal [8]	BMJ Glob Health	2021 Dec	Structural barriers intensify the gender gap in health research.
Hastie M. J. Lee A. Siddiqui S.	Misconceptions about women in leadership in academic medicine [19]	Can J Anaesth	2023 May	Institutions must create supportive environments and fair opportunities.
Bosco L. Lorello G. R. Flexman A. M.	Women in anaesthesia: a scoping review [11]	Br J Anaesth	2020 Mar	Gender discrimination is the main factor responsible for academic career advancement.
Gonzalez L. S. Fahy B. G. Lien C. A.	Gender distribution in United States anaesthesiology residency programme directors: trends and implications [20]	Br J Anaesth	2020 Mar	Recruiting more women in anaesthesiology, together with interventions to recruit female academic faculty members, reduces the effects of gender bias on recruitment, promotion, and departmental culture.
Ryan M. K. Morgenroth T.	Why We Should Stop Trying to Fix Women: How Context Shapes and Constrains Women’s Career Trajectories [21]	Annu Rev Psychol	2024 Jan	The most successful strategy would encourage organisations to give all women something extra to support them.
Tricco A. C. Nincic V.Darvesh N. et al.	Global evidence of gender equity in academic health research: a scoping review [6]	BMJ Open	2023 Feb	There is a need to identify interventions to promote gender equality at all levels of organisations.
Caywood K. Darmstadt G. L.	Gender mainstreaming at 25 years Toward an inclusive, collaborative, and structured research agenda [7]	J Glob Health	2024 Jan	Inclusive, collaborative and structured research can better harness academia to assist practitioners and advocates in realising the relevance of gender mainstreaming and the potential for impact in the health and development sectors.
Schwartz R. Williams M. F. Feldman M. D.	Does Sponsorship Promote Equity in Career Advancement in Academic Medicine? [5]	J Gen Intern Med	2024 Feb	Leaders must strive to create a culture of sponsorship relevant to career advancement in medicine.
Khounsarian F. Abu-Omar A. Aida Emara A. et al.	A trend, analysis, and solution on women’s representation in diagnostic radiology in North America a narrative review [22]	Clin Imaging	2024 May	A more diverse and representative discipline of radiology contributes to better patient care and satisfaction.
Bellini M. I. Adair A. Fotopoulou C.	Changing the norm towards gender equity in surgery the women in surgery working group of the Association of Surgeons of Great Britain and Ireland’s perspective. [3]	J R Soc Med	2019 Aug	A diverse and inclusive environment should be favoured.

4. Discussion

Regarding the first question, a review of several articles reveals significant disparities between female and male leadership in the world of academia. According to literature [12] on women academics in the United States, women are perceived as less competent than men, receive lower teaching evaluation scores, fewer citations, and have their publications regarded as lower quality than those authored by men. These disadvantages extend to application and candidate review processes. Recommendation letters for women tend to be more concise, focus on gender-specific attributes, and encompass private lifestyle details. Even if qualifications and expertise between women and men are equivalent, women are still rated as inferior. These biases directly affect women’s tenure, promotion, and retention in academia, and advance environments incompatible with family life.

In response, the University of California, Davis, started a campaign promoting flexibility in academic culture and raising awareness of family-friendly policies such as parental leave, tenure clock extensions, and part-time contracts. This initiative fostered cultural change, introducing outstanding work-life balance, reduced gendered language in recommendation letters, and achieved gender parity in assistant professor hiring. A second initiative boosted the recruitment and advancement of women faculty compared to other University of California campuses. It included equity counselling systems, workshops, gender analysis, and equity awards.

Evidence-based policies to increase women’s hiring for academic positions should address various challenges. To start with, many young women enter academia during their reproductive years, and between earning their Ph.D. and obtaining tenure, they often delay milestones such as marriage and childbirth. A survey of over 4,000 faculty from 507 academic institutions found that women are more likely than men to remain single and delay starting families before achieving tenure, with fewer children on average. Another study found that after having their first child, 43% of women, compared to 23% of men, abandoned full-time work, with significantly higher dropout rates among faculty with children [17]. Secondly, regardless to family and caregiving commitments, women and men share professional aspirations in research productivity, clinical care, and teaching. However, women often emphasize collaborative and community-oriented values consistently to gender expectations, such as mentorship, teaching, and professional flexibility. At the same time, men increasingly focus on research and clinical outcomes, leading to greater recognition. Conversely, women have career choices to remain engaged in these collaborative activities.

In addressing the second question, research highlights that fields like general medicine and pediatrics already attract predominantly female workforces, contrary to fields such as surgery, which have fewer women. Gender stereotypes probably contribute to these disparities. Stereotypes, whether positive or negative, form early in life through exposure to family attitudes, media, and cultural norms [18]. Women and men can be stereotyped in relationship on traditional gender roles, and generalized images can be formed that many people believe represent a typical man or woman. Gender roles are described using terms like “agentic” for authoritative, assertive, and dominant men, and “communal” for emotional, nurturing, and collaborative women[12].

Women in leadership roles often display traits traditionally attributed to men, and are referred to as “alpha women.” These individuals are portrayed as strong, extroverted, ambitious, assertive, and competitive, and frequently holdi significant leadership positions. Maslow’s 1939 study Dominance, Personality, and Social Behavior described dominant women as self-confident, balanced, independent, and rarely embarrassed or shy. His research was based on interviews with 130 women and 15 men aged between 20 and 28. The women belonged to the middle class, attended university, 75% were married, 75% Protestant, 20% Jewish, and 5% Catholic. Maslow pointed out that someone who displayed high dominant power would be a great leader although not all women would become one. According to Maslow, dominant women showed self-confidence, greater balance, independence, rarely embarrassed, awkward, shy, or fearful as compared to non-dominant women. They preferred to be treated as a “person” rather than a “woman,” lacked feelings of inferiority, and generally made no concessions associated with being inferior, weak, and in need of special attention [13].

As a consequence, organizations should refrain from recruiting or evaluating performance based on gender stereotypes or traditional “ideal worker” norms as they are constructed on male standards. Rather, they should reconsider the skills of the “ideal worker”, challenge the socio-cultural barriers that women encounter, and implement gender-sensitive approaches [8]. Organizations should encourage gender equity [22], deconstruct systemic disadvantages, and promote female leadership by designing inclusive environments that value multifaceted leadership styles. Conducive work environments should be promoted where resources and opportunities are shared equitably, strengths are recognized and improved, and differences in leadership and management styles are valued [20]. In this regard, an encouraging movement toward gender equality has been positively evolving over the past 15 years [19].

In response to the third question, obstacles for women to leadership positions are emphasized. The main problem for women appears to be limited available time. Conducting research, publishing in academic journals, and raising funding requires time, which men often accomplish with extra work hours. Women, instead, typically have household and caregiving duties, which leave them less time for career progress [21]. In addition to time constraints, numerous factors contribute to salary disparities. When women have children, they often reduce their working hours, having a negative effect on career progression and income. Minimizing gender inequality needs shifting from expecting individual women to overcome obstacles to addressing structural inequities. Interventions should encompass fair distribution of household duties, inexpensive and available childcare, parental leave, and challenge meritocracy stereotypes [14]. Mentorship can be key solution to these issues because it can provide women with motivation, assistance, and career development opportunities. Effective mentors, particularly female mentors, offer psychological and social support and encourage career advancement, which may lead to more publications, funding, and career advancements [16]. In addition, sharing stories of successful women is a crucial strategy in inspiring others to chase leadership positions. A growing awareness of the advantages of multifaceted leadership, which includes women in decision-making roles, will reshape professional sceneries, particularly in fields which require innovative research and patient care. These success stories function as powerful motivators and encourage more women to get into leadership roles and contribute to different leadership styles [15].

5. Conclusions

This review of female leadership points out the challenges and obstacles that women encounter in their professions, starting with hiring and promotion processes. Women who overcome gender-based barriers often strive to keep leadership positions, particularly when balancing motherhood. Women leaders are distinguished for transformational leadership style, which entails inclusive and empathetic management, in contrast to the autocratic and authoritarian approaches of male leaders. Nonetheless, women who get leadership roles often exhibit dominant, assertive, and controlling characteristics, which are traditionally associated with masculine traits.

According to the selected studies, minimizing obstacles and barriers for women demand flexible schedules, mentorship, coaching, and raising awareness. In addition to gender biases and stereotypes, the main obstacle that emerges is the issue of motherhood, which is often underestimated and continues to be responsible for women slowing down or abandoning their professional careers. Organizations should provide mothers for support services, networking opportunities, training programs, and review recruitment and promotion criteria to allow women’s career progress.

Academic studies confirm that women tend to apply a transformational leadership in contrast to the autocratic and assertive male leadership. Women leaders stress listening, participation, and organizational well-being. Refusing women access to leadership roles dissipates human talent and limits perspectives. Research accomplished over the years emphasize an increasing presence of women in numerous public and private sectors, and their gradual progress in traditionally male-dominated fields. However, leadership roles continue to be preferentially assigned to men. Hence, continued research into female leadership is essential for monitoring progress and fostering actions that advance gender and allow women to prosper in top leadership positions.