"That's not Science!"
Disrespect, Dismissal and Censorship of Women Scientists
Jerilynn C. Prior BA, MD, FRCPC
On International Women’s Day, 2022, we celebrate the importance of women. We women, although not suffering the highest hospitalization and death rates, have been most burdened by the necessary adaptations to this prolonged and difficult pandemic. It is also time to acknowledge the everyday barriers that women in Science (and Medicine) face. A serious hurdle is the mostly unconscious bias that ‘Women’s Health’, including menstrual cycles and pre- and perimenopausal experiences, are pervasively viewed as NOT Science.
When my close relative asserted, “That’s not Science!”, he and I were facing common grief and loss. We were seeing each other again after a gap and catching up with each other’s lives. I was describing my excitement in discovering that marathon-training did not disrupt menstrual cycles, but rather decreased ovulation or egg-release. I was then a not-yet-tenured medical school Assistant Professor.
His words almost had the intended effect—to shut me up. Instead I asked a fundamental question: What IS Science?
Science is a human endeavour that systematically, ideally in an unbiased manner, describes, examines and clearly reports on any entity, phenomenon or observable event. “Discovery” does not become “fact” until it is peer-reviewed and published. Thus, publication is of crucial importance. The process of new data evaluation should be a rigourous, transparent, and equitable.
The top-of-the-line publication of medical science is in five major (English) general medical journals that have the highest “Impact Factor” (IF), meaning their publications are most often quoted in subsequent science. These five are, in descending IF order: New England Journal of Medicine (NEJM), Lancet, Journal of American Medical Association (JAMA); British Medical Journal (BMJ)and the Canadian Medical Association Journal (CMAJ). First the journal editor (a person ideally of exemplary scientific status) decides the manuscript is/is not of value. If potentially publishable, the editor (usually a “he”) invites other scientists with expertise in the area of research (who are also usually “he”) to review it, analyze the data, make suggested changes and recommendations. There are three potential outcomes: the article is published, major revisions may/may not lead to publication, or the work is rejected. This evaluation process, fundamental to Science, is called “peer review.” Despite the pervasive, increasing commodification of scientific publication, with for-profit journals and increasing open access “article processing charges” (APC) that now average $3,000/publication, peer review continues to be undertaken by volunteer, unpaid scientists.
The topic of scientific investigation is anything observable: a nano-particle that replicates in living tissues creating a pandemic, disrupting the entire world order; a minute speck of “light” through the most powerful space telescope; or ovulation (egg release) in a whole population of spontaneously menstruating women. The same scientific processes apply, no matter the scope, focus of research or type of study.
My close relative who asserted my research was “not Science,” has an honours university degree (like me); he is brilliant and a born philosopher. But his education and training are at least seven years less than mine; his only science exposure was in a required high school lab. Yet he confidently declared that menstrual cycle research was not Science. What gave him that right? Why did he have that unjustified confidence?
Society and Culture give Men, some in particular, the audacity to deny the validity of research related to women’s reproduction and health. Similarly, men’s entitlement allowed an international gynecology association to decide, without new data, that the expected/normal cycle length should be changed. Does it not matter that half of all people have menstrual cycles that are key to human reproduction and to the very survival of homo sapiens’? There is also a cultural menstrual taboo 1 2. This appears to have ‘metastasized’ to include not only all women’s non-disease topics but all Science by women 3.
Later we collaborated with Norwegian public health researchers to determine, for the first time, the likelihood that any given menstrual cycle in a population of women would be ovulatory. We learned that a quarter to a third (24-37%) of all menstrual cycles in women with predictable, 3-5 week-long cycles, who were not on the Pill, did not release an egg or ovulated with a short luteal phase (which means too few days from egg release until flow for a fertilized egg to grow 4.) Although few have documented this, a short luteal phase cycle is usually infertile 5. To determine ovulation, we measured progesterone in a sample of blood on a random cycle day. If the woman was in the second half of her cycle and the progesterone level was above an agreed on “ovulation threshold” 6 7, we considered the cycle normally ovulatory.
With a shiver of anticipation, I submitted that manuscript to JAMA in January, 2014. It was rejected without peer review; the associate woman editor wrote, manuscripts are rejected “whose subject matter does not meet our current editorial priorities” 3. We submitted this again and again over the next 1.5 years. It was rejected by all major medical journals without peer review. It was finally published in August, 2015 by the Public Library of Science ONE (PLOS ONE) with an impact factor of 3.24 8. Despite its low-IF publication, that paper has now been cited 78 times.
Another important women’s health issue is bone growth and potential effects of The Pill (combined hormonal contraceptives, CHC). I had analyzed baseline bone density in women ages 25-45 in the randomly sampled Canada-wide Canadian Multicentre Osteoporosis Study (CaMos, www.camos. org), finding those who ever used CHC had lower bone density 9. Higher “peak hip bone” gained during the teen years means a lower lifetime risk of breaking a hip. Investigating the 2-year bone change in CaMos teen women (ages 16-19), we discovered 75% used CHC; they gained less hip-region bone. In September, 2016, we submitted this new research to JAMA. It was subsequently rejected by JAMA and all major general medical journals without peer review. It was finally published in July, 2017 by the Journal of Musculoskeletal & Neuronal Interactions (IF=2.041) 10. Our later international meta-analysis confirmed significant bone loss with teen CHC use 11.
Being told by a close relative, “it’s NOT Science!” is one thing. That same message from editors of major medical journals and you feel disrespected and devalued. That is emotionally and professionally difficult. Revising, reformatting and resubmitting scientific articles requires hours, weeks, if not months, of additional work. It also increases the likelihood of publishing in lower IF and/or more expensive APC-requiring journals. Furthermore, these manuscript rejections and associated delays decrease a woman scientist’s academic advancement. In the early 1990s, I did an innovative controlled trial with highly significant results. Cyclic medroxyprogesterone, acting through the osteoblast progesterone receptor, increased bone density in normal-weight younger women without periods (amenorrhea) or with other cycle or ovulation disturbances. It was rejected six times before it was finally published 12. That delayed publication almost cost me tenure and my valued university job.
We must empower women scientists to fight back—first to make the bias visible, and then to push the Science/Medicine publication system to become accountable. How can we do that? First, by documenting bias. This is what we did by analyzing what the major medical journals did publish in the two issues following our rejections—primarily studies of diseases and drugs, by mostly men authors 3. We found that only three of 74 scientific papers were about normal/natural physiology, and none of these related to women 3. We also documented the timing, letters of rejection, gender of editors-in-chief and of the editorial desk letter-writers (junior editors, mostly women) plus the “IF deficit.” Today there is a price to pay for discovering innovative physiology about taboo topics.
Finally, our recently published exposé demands major medical journals hire an editorial desk “gender champion” with powers to ensure equitable peer review, establish a transparent adjudication process or authors who feel their manuscripts are unfairly rejected, and for double-blind, gender-equivalent peer review. Here’s to equitable Science that is fair for women scientists!
Reference List
1. O'Brien M. The politics of reproduction. London: Routledge and Kegan Paul 1981.
2. Sole-Smith V. The point of a period: Age-old taboos against menstruation have led to a lack of research on how women's cycles work, with serious consequences for their health. Sci Am 2019;320(5):33-+. doi: 10.1038/scientificamerican0519-32
3. Kalidasan D, Goshtasebi A, Chrisler J, et al. Prospective analyses of sex/gender-related publication decisions in general medical journals: editorial rejection of population-based women's reproductive physiology. BMJ Open 2022;12(2):e057854.
4. Jones GES. Some Newer Aspects of the Management of Infertility. Jama 1949;141(16):1123-29. doi: DOI 10.1001/jama.1949.02910160013004
5. Crawford NM, Pritchard DA, Herring AH, et al. Prospective evaluation of luteal phase length and natural fertility. Fertil Steril 2017;107(3):749-55.
6. Israel R, Mishell DR, Jr., Stone SC, et al. Single luteal phase serum progesterone assay as an indicator of ovulation. Am J Obstet Gynecol 1972;112(8):1043-46.
7. Shepard MK, Senturia YD. Comparison of serum progesterone and endometrial biopsy for confirmation of ovulation and evaluation of luteal function. Fertility and Sterility 1977;28(5):541-48.
8. Prior JC, Naess M, Langhammer A, et al. Ovulation Prevalence in Women with Spontaneous Normal-Length Menstrual Cycles - A Population-Based Cohort from HUNT3, Norway. PLOS One 2015;10(8):e0134473. doi: 10.1371/journal.pone.0134473
9. Prior JC, Kirkland S, Joseph L, et al. Oral contraceptive agent use and bone mineral density in premenopausal women: cross-sectional, population-based data from the Canadian Multicentre Osteoporosis Study. Can Med Assoc J 2001;165:1023-29.
10. Brajic TS, Berger C, Schlammerl K, et al. Combined hormonal contraceptives use and bone mineral density changes in adolescent and young women in a prospective population-based Canada-wide observational study. J Musculoskelet Neuronal Interact 2018;18:227-36.
11. Goshtasebi A, Berger C, Barr SI, et al. Adult Premenopausal Bone Health Related to Reproductive Characteristics-Population-Based Data from the Canadian Multicentre Osteoporosis Study (CaMos). Int J Env Res Pub He 2018;15(5)
12. Prior JC, Vigna YM, Barr SI, et al. Cyclic medroxyprogesterone treatment increases bone density: a controlled trial in active women with menstrual cycle disturbances. American Journal Medicine 1994;96:521-30.
