Abstract
Purpose
This cross-sectional study evaluated the prevalence of inclusive author submission guidelines across ophthalmology journals.
Methods
Journals were identified from the 2021 Journal Citations Report (Clarivate Analytics). Independent reviewers rated each author submission guideline as “inclusive” for satisfying at-least one of six criteria: i) included examples of gender inclusive language; ii) recommended the use of gender-inclusive language; iii) distinguished between sex and gender; iv) provided educational resources on gender-inclusive language; v) provided a policy permitting name changes (e.g., in case of gender and name transition); and/or vi) provided a statement of commitment to inclusivity. The primary objective was to investigate the proportion of journals with “gender-inclusive” author submission guidelines and the elements of the gender-inclusive content within these guidelines. A secondary objective was to review the association between “gender-inclusivity” in author submission guidelines with publisher, origin country, and journal/source/influence metrics (Clarivate Analytics).
Results
Across 94 journals, 29.8% journals were rated as inclusive. Inclusive journals had significantly higher relative impact factor, citations, and article influence scores compared to non-inclusive journals. Of the 29.8% of inclusive journals, the three most common domains were inclusion of an inclusivity statement (71.4% of inclusive journals), distinguishing between sex and gender (67.9%), and provision of additional educational resources on gender reporting for authors (60.7%).
Conclusion
A minority of ophthalmology journals have gender-inclusive author submission guidelines. Ophthalmology journals should update their submission guidelines to advance gender equity of both authors and study participants and promote the inclusion of gender-diverse communities.
Introduction
Gender refers to how an individual wishes to be perceived and is based on psychosocial and cultural factors. 1 Sex is a static and typically binary term referring to one's biological classification. 1 Although a major social determinant of health, gender is not systematically assessed in most research endeavours. 2 Thus, individuals are commonly assumed to fall under one of two binary gender classifications: cisgender woman or cisgender man. This assumption fails to consider nonbinary gender groups such as individuals who identify as transgender, genderqueer, or gender expansive. Gender disparity has been documented in educational institutions, academic disciplines, professional societies, clinical trials, grant funding, awards, patents, and editorial boards.3–13 In ophthalmology, there is little research investigating ocular health outcomes in the subgroup of gender diverse individuals. 14 The inclusion of such individuals into ophthalmic research is important as previous work has suggested that they may experience a high prevalence of ocular disease and face unique barriers to accessing care. Furthermore, there is very little work exploring the prevalence of ocular diseases in gender diverse groups.15,16 However, despite the limited understanding of ocular disease and barriers to care in these groups, the research process for ophthalmology researchers and clinicians is often unaccommodating of gender diverse identities. 1
Although the ethical and scientific imperative of gender equity is widely recognized, few scholarly journals describe gender-inclusive research practices in their submission guidelines.1,17 A recent cross-sectional analysis of 121 active obstetrics and gynecology journals found that only 33.9% provided explicit author instructions on gender-inclusive research practices. 17 In ophthalmology, one report indicated that only one of the ten highest impact factor journals provided detailed guidelines on sex and gender reporting in 2022. 1 However, that measure was a preliminary evaluation of select ophthalmology journals, and did not evaluate the majority of other journals nor did it investigate the topic in further (quantitative and qualitative) depth than the mentioned statistic. 1 It is unknown whether other ophthalmology journals have similarly detailed guidelines on sex and gender reporting, and whether these guidelines additionally mandate the use of gender-inclusive research practices. Gaps in author submission guidelines may contribute to the persistent underrepresentation of gender minority groups in ophthalmic research. 14
Gender identity reporting is often incorrectly synonymized with sex and has historically excluded those from marginalized gender identities. 18 Further, gender reporting is often lacking in the ophthalmic literature. 18 For this reason, this study focused primarily on gender- rather than sex-inclusivity. The primary objective was to evaluate the frequency and content of gender-inclusive research practices among ophthalmology journal submission guidelines, based on six pre-defined criteria concerning evidence of inclusivity of gender diverse authors and/or promotion of proper gender reporting for study participants. Our secondary objective is to determine whether gender-inclusive and gender-non-inclusive journals differ with respect to metrics of research influence such as Journal Impact Factor (JIF).
Methods
Our methodology has been previously published in another medical specialty context. 17 In April 2023, the 2021 Journal Citation Reports database (JCR; Clarivate Analytics) was queried to retrieve all journals registered under the category “ophthalmology.” From this database, journal metrics were acquired including publication language, publisher, country of origin, source characteristics, and research influence metrics. Source characteristics included total documented items, citable items, and publication model (i.e., subscription-based, open-access, or hybrid). Research influence metrics included cumulative citations, 2021 JIF, five-year JIF, immediacy index, and normalized impact metrics (i.e., 2021 journal citation indicator [JCI], article influence score, normalized Eigenfactor, and JIF percentile). Extensive definitions of all included metrics have been detailed. 17 All metrics were categorized as absolute metrics (total citations, citable items, total items, 2021 and 5-year JIF, immediacy index, and proportion of items published via open-access gold) and relative measures (JIF quartile and percentile, JCI, normalized Eigenfactor, article influence score).
The online author submission guidelines of included journals were surveyed for their use of gender-inclusive research practices. For journals with non-English guidelines, an author with native understanding of the language interpreted the guideline. In other cases, a tandem of Google Translate, DeepL Translate, and Microsoft Translator was used to perform English translation where disagreements between these software were adjudicated through team discussion. For journals that did not have online author submission guidelines, the editorial board was emailed to request information. Three independent reviewers evaluated the entirety of each journal submission guideline for evidence of gender-inclusivity, which are described elsewhere. 19 Ophthalmology journals were categorized as “inclusive” if their submission guidelines provided authors with specific instructions on gender-inclusive research practices and “non-inclusive” if no specific instructions were provided. From inclusive journals, we collected excerpts of these specific instructions. The content of gender-inclusive instructions was extracted where available. As a standalone metric, we also assessed whether journal submission systems permitted use of gender diverse titles, such as “Mx.” or free text entry titles, in addition to binary titles (e.g., “Ms.”, “Ms.”) when entering authors into the system. Disagreements between reviewers were resolved via discussion with the senior author (FK).
We analyzed the content of gender-inclusive research instructions across all ophthalmology journals, as related to inclusivity of researchers and inclusive reporting for study participants. Criteria for attaining inclusive journal status was conducted using previously validated methodology, which delineated whether journals i) included examples of gender inclusive language; ii) recommended the use of gender-inclusive language; iii) distinguished between sex and gender; iv) provided additional educational resources for authors; v) provided a name change policy; and/or vi) provided an inclusivity statement. 17 Of note, the recommendation of using “women-centered” language was tracked across journals, though like one previous work, this criterion was not considered to be gender-inclusive. 17 Examples of excerpts from author guidelines that satisfy each criteria are documented in Supplemental Table 1. We calculated the proportion of journals that were inclusive among 1) ophthalmology journals with 2021 JIFs and 2) all ophthalmology journals (those with and without 2021 JIFs). Furthermore, we compared journal metrics, source characteristics, and research influence parameters between inclusive and non-inclusive journals using descriptive statistics and a quantile regression model that employed 500 bias-corrected bootstrap resampling which corrected for multiple comparisons. 20 . Continuous variables were summarized using medians and interquartile ranges (IQRs), median difference (MD) with 95% confidence intervals (95% CI), and categorical variables with frequencies and percentages. Statistical significance was based on an alpha of 5%. All statistical analyses were performed in RStudio 2022.02.0 + 443.
Results
A total of 94 indexed ophthalmology journals were identified, all of which had publicly accessible author guidelines and were therefore included in analysis (Supplemental Table 2). Most ophthalmology journals (89/94; 94.7%) were published in English, while the rest were published in German (4/94; 4.3%), French (1/94; 1.1%), Portuguese (1/94; 1.1%), or Turkish (1/94; 1.1%). A considerable proportion of journals hailed from the United States (31/94; 33.0%) or United Kingdom (26/94; 27.7%). Table 1 provides detailed information on each included journal's language, country of origin, and JIF prevalence.
Summary of included journals, stratified by language, country of origin, and journal impact factor.
Overall, 28/94 (29.8%) of journals were inclusive. Table 2 exhibits a comparison of inclusive versus non-inclusive journals, stratified by language, country of origin, and publisher. All inclusive journals and 61/66 (92.4%) of non-inclusive journals were published in English. Among the inclusive journals, the top two-most represented nations were United States (10/28; 35.7%) and the United Kingdom (10/28; 35.7%); among the non-inclusive journals, these corresponded to 21/66 (31.8%) and 16/66 (24.2%) of journals, respectively. Table 2 exhibits the full list of represented nations. Elsevier was the most represented publisher and handling 13/28 (46.4%) of inclusive journals. Non-inclusive journals were most often affiliated with Lippincott Williams and Wilkins Ltd. and Taylor & Francis, which published 12/66 (18.2%) and 10/66 (15.2%) of non-inclusive journals, respectively. Finally, 68/94 (72.3%) of journals offered gender-diverse options for author title entry on their associated submission system, including titles such as “Mx.” or permitting the user to type their preferred title.
Comparison of inclusive versus non-inclusive journals, stratified by journal characteristics.
Table 3 tabulates journal metrics along with bootstrapped median differences with 95% confidence intervals between inclusive and non-inclusive journals. Inclusive and non-inclusive journals had a relatively similar proportion of journals that lacked an assigned JIF, constituting 10/28 (35.7%) and 22/66 (33.3%) of journals, respectively. Among journals with an assigned JIF, inclusive journals had significantly greater 2021 JIFs (mean difference [MD]: 1.84, 95%CI [0.71, 3.49]), 5-year JIFs (MD: 1.68, 95%CI [0.69, 4.23]), 2021 JCIs (MD: 0.49, 95%CI [0.12, 0.71]), normalized Eigenfactors (MD: 0.81, 95%CI [0.14, 1.4]), and article influence scores (MD: 0.42, 95%CI [0.09, 0.73]) compared to non-inclusive journals. As shown in Table 3, inclusive journals tended to occupy more competitive JIF quartiles, while the opposite trend was noted among non-inclusive journals. Differences across other absolute metrics did not reach statistical significance, including total citations, item counts, and immediacy index.
Comparison of inclusive versus non-inclusive journals, stratified by journal metrics.
Table 4 summarizes the six domains of inclusive journals. The most common domain was the inclusion of an inclusivity statement, which applied to 20/28 (71.4%) of journals. For the other domains, 19/28 (67.9%) of journals made clear distinctions between the definitions of sex and gender, 17/28 (60.7%) provided additional educational resources for authors, 13/28 (46.4%) provided examples of gender-inclusive language and recommendations for gender-inclusive language, and 7/28 (25.0%) of inclusive journals outlined a name change policy. Supplemental Table 1 summarizes qualitative excerpts taken from author guidelines of inclusive journals. Among all publishers, Elsevier-affiliated inclusive journals consistently broached all inclusivity domains except for name change policies. Inclusive journals affiliated with other publishers did not broach more than three inclusivity domains, and journals affiliated with four of nine publishers only touched on a single domain.
Summary of the domains of inclusivity assessed across included journals.
Discussion
In our comprehensive set of 94 ophthalmology journals, only 29.8% had gender-inclusive author submission guidelines. No journal simultaneously achieved all gender-inclusive criteria, and a considerable proportion of journals achieved fewer than half of the criteria. The majority of inclusive journals were published in English and based in the United States or United Kingdom. Non-inclusive journals had similar publishing characteristics but demonstrated greater heterogeneity in publication language and country of origin. While absolute journal metrics (i.e., total citations, citable items, total items, immediacy index, and Open Access Gold) were not significantly different between inclusive and non-inclusive journals, relative metrics including JIF percentile, 2021 JCI, article influence scores, and normalized Eigenfactors were significantly higher among inclusive journals.
Research is a large component of medical training and careers, yet academia remains incompletely inclusive of gender-diverse individuals. Despite the 2016 National Institute of Health (NIH) strategic plan to promote better understanding and representation of sexual and gender minority groups, research continues to conflate sex and gender, especially for clinical data. 1 One study in transplant research found that 57.5% of 2107 published manuscripts neglected to differentiate between “sex” and “gender,” using related terms interchangeably. 21 In ophthalmology, a recent scoping review was unable to identify any studies that examined gender-diverse-related care inequities, which embodies a broad and ongoing research gap that can depreciate patient care. 14 Indeed, there remains a critical lack of detailed journal guidelines on distinguishing sex from gender in ophthalmology, which may reflect a systemic lack of awareness and perceived importance.1,22 For example, gender-diverse physician researchers may face greater social ostracization than their peers and potentially withhold self-identification or research participation, in spite of their lack of visibility on publishing platforms.23,24 We hypothesize that the inclusion of gender-diverse researchers may increase investigation and remediation of care disparities across gender diverse groups, resulting in clinically useful granularity about ophthalmic access and outcomes. 17
Dunn et al. evaluated obstetrics and gynecology journals and found that only 33.9% mandated gender-inclusive language and other gender-inclusive research practices, which is similar to the present study's finding of 29.8%. 17 Dunn et al. also found that inclusive journals had greater impact metrics, normalized metrics, and source metrics than non-inclusive journals, which was replicated in our study. 17 It is apparent that while few absolute metrics are significantly higher among inclusive journals, the majority of relative citation, influence, and impact factor metrics are significantly higher among inclusive journals. Relative metrics tend to be more reliable estimates than absolute parameters due to their mathematical handling of outlier journals. We therefore conclude that inclusive ophthalmology journals had greater impact and interaction metrics with researchers. It should be recognized that gender inclusive guidelines are correlated with, not causative of, higher research metrics. Indeed, journals with such guidelines may be more likely to have larger editorial boards and infrastructure resources (from the publisher) to guide attention toward gender inclusivity.
A large proportion of inclusive ophthalmology journals were published by a select group of publishers, the most prominent of which was Elsevier. 17 Moreover, Elsevier-affiliated journals were more likely to satisfy a greater number of inclusivity domains than other publishers that were affiliated with inclusive journals. These findings indicate that journal inclusivity may depend more on the attitudes and policies held by the responsible publisher, rather than the editorial board of a journal subsidiary. Qualitatively, Dunn et al. showed that 33.9% of obstetrics and gynecology journals consistently provided guidance criteria regarding gender-inclusive language. 17 Our quantitative findings differed in that ophthalmology journals most commonly provided gender diversity statements (71.4% of journals) and distinct definitions of sex and gender (67.9%). These differences are likely attributed to contextual cultural factors that differ between specialties, which in themselves deserve further qualitative investigation.
Inclusive research guidelines provide a much-needed framework for positive change amid rapidly changing gender demographics globally. Future research may focus on the qualitative perspectives of gender-diverse researchers, both within and outside of ophthalmology, who may face barriers to representation and advancement in academia, and prospective investigations may also be helpful to correlate whether lack of inclusive author guidelines is associated with lower rates of gender-inclusive practice (e.g., conflation of sex and gender, poor enrollment of gender minority groups). Future work is also needed to investigate potential for eye care gaps that disadvantage gender-diverse individuals. Indeed, the literature suggests that gender diverse identity is associated with various morbidities. For instance, eating disorders more often affect gender diverse individuals than their cisgender peers, 25 which requires increased awareness of potential ophthalmic sequelae from nutritional deficiencies (e.g., vitamin B1, vitamin A), oculoplastic/orbital complications of fat atrophy or loss, hemorrhagic complications of bulimia, etc. Hormone supplementation therapy may also promote ophthalmic manifestations; studies of estrogen therapy, especially in aging females, suggests some role of estrogen (or its lacking) in the manifestation of dry eye, cataract, glaucoma, Leber's hereditary optic neuropathy, and age-related macular degeneration. 26
The major strength of this study is its comprehensive inclusion of all ophthalmology journals indexed by Clarivate Analytics, including emerging journals that do not yet have an assigned JIF. One limitation is the restriction of analysis to gender inclusivity, precluding consideration of other sociodemographic factors such as age, race, ethnicity, and socioeconomic status. Consequently, journals that mandated diversity practices that were unrelated to gender may have been rated as non-inclusive. Second, our criterion for gender inclusivity was lax in that journals only needed to satisfy one gender inclusivity domain to be considered inclusive. It is difficult to determine the threshold at which a journal becomes inclusive. Third, we did not investigate reasons for the absence of inclusive gender guidelines. Another source of bias is the potential influence of politically repressive policies on diversity from certain countries of origin, which may preclude local journals or their associated publishers from comfortably embracing inclusivity measures. Finally, whether gender inclusive publication guidelines increase the inclusion of gender diverse individuals in research, as researchers or subjects, is undetermined.
This cross-sectional analysis demonstrated a lack of gender-inclusive author guidelines among ophthalmology journals. Journals that recommended gender-inclusive research practices were more likely to have higher impact and citation metrics. It is notable that publishers appeared to have considerable degree of influence over the inclusivity of their journals’ author submission guidelines, rather than being entirely specific to a journal's editorial board. We recommend that ophthalmology journals update their author guidelines to promote inclusion of marginalized and underrepresented groups, which may improve gender-based disparities in eye care, research, and academic advancement.
Supplemental Material
sj-docx-1-ejo-10.1177_11206721241259806 - Supplemental material for Gender inclusivity of ophthalmology journal submission guidelines and associated research metrics
Supplemental material, sj-docx-1-ejo-10.1177_11206721241259806 for Gender inclusivity of ophthalmology journal submission guidelines and associated research metrics by Brendan K. Tao, Jim S. Xie, Rachel Leong, Matton Xia, Anne Xuan-Lan Nguyen, Jennifer Ling, Nawaaz Nathoo, Edsel B. Ing, Radha P. Kohly and Faisal Khosa in European Journal of Ophthalmology
Supplemental Material
sj-docx-2-ejo-10.1177_11206721241259806 - Supplemental material for Gender inclusivity of ophthalmology journal submission guidelines and associated research metrics
Supplemental material, sj-docx-2-ejo-10.1177_11206721241259806 for Gender inclusivity of ophthalmology journal submission guidelines and associated research metrics by Brendan K. Tao, Jim S. Xie, Rachel Leong, Matton Xia, Anne Xuan-Lan Nguyen, Jennifer Ling, Nawaaz Nathoo, Edsel B. Ing, Radha P. Kohly and Faisal Khosa in European Journal of Ophthalmology
Footnotes
Authorship
All authors attest that they meet the current ICMJE criteria for authorship.
Contribution statement
Conception/Design/Acquisition/Analysis/Interpretation (BT, JX, JL, AXLN), Acquisition (MX, RL), Drafting/Revision (all authors), Final Approval (all authors), Agreement of Accountability (all authors).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: BT is the recipient of the Eye Foundation of Canada Scholarship for medical students. FK is the recipient of the Michael Smith Health Research BC Award (2023–2028). This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Statement of ethics
Exempt from institutional review board approval (under article 2.4 of the Tri-Council Policy Statement) since data was entirely extracted from publicly available sources. No identifiable information is revealed in this work.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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