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Gender bias in reference letters for residency and academic medicine: a systematic review
  1. Shawn Khan1,2,
  2. Abirami Kirubarajan1,2,3,
  3. Tahmina Shamsheri4,
  4. Adam Clayton1,2,
  5. Geeta Mehta5,6
  1. 1University of Toronto, Toronto, Ontario, Canada
  2. 2Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  4. 4Department of Interdisciplinary Studies, McMaster University, Hamilton, Ontario, Canda
  5. 5Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, Toronto, Canada, Ontario, Canada
  1. Correspondence to Dr Geeta Mehta, Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada; geeta.mehta{at}


Reference letters play an important role for both postgraduate residency applications and medical faculty hiring processes. This study seeks to characterise the ways in which gender bias may manifest in the language of reference letters in academic medicine. In particular, we conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched Embase, MEDLINE and PsycINFO from database inception to July 2020 for original studies that assessed gendered language in medical reference letters for residency applications and medical faculty hiring. A total of 16 studies, involving 12 738 letters of recommendation written for 7074 applicants, were included. A total of 32% of applicants were women. There were significant differences in how women were described in reference letters. A total of 64% (7/11) studies found a significant difference in gendered adjectives between men and women. Among the 7 studies, a total of 86% (6/7) noted that women applicants were more likely to be described using communal adjectives, such as “delightful” or “compassionate”, while men applicants were more likely to be described using agentic adjectives, such as “leader” or “exceptional”. Several studies noted that reference letters for women applicants had more frequent use of doubt raisers and mentions of applicant personal life and/or physical appearance. Only one study assessed the outcome of gendered language on application success, noting a higher residency match rate for men applicants. Reference letters within medicine and medical education exhibit language discrepancies between men and women applicants, which may contribute to gender bias against women in medicine.

  • education & training (see medical education & training)
  • medical education & training

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  • Twitter @_shawnkhan, @geetamehta

  • AK and TS contributed equally.

  • Presented at A research poster of this work was presented at the Canadian Conference for Medical Education (CCME) in 2019.

  • Contributors All included authors made substantial contributions to: the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content; and final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. AK and TS share second-authorship.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.