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Spanish Doctoral Thesis in Health Sciences on Gender (1976–2022)

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Abstract
Objective: To quantitatively analyze the production of Doctoral Theses on health issues related to gender in Spain. Method: Quantitative synthesis of the productivity indicators of the Doctoral Theses de-fended in Spanish Universities between 1976 and 2022, obtained from the Spanish TESEO data-base. Descriptive analysis, materialized in tables and graphs, and time series model, based on the Holt-Winters model methodology. Results: 18.75% of the defended Doctoral Theses represents the scientific production of the Universities. Madrid is where the greatest number defend themselves with 37.5%. One in three authors are graduates in medicine. The theme of the Theses is gender violence in 25.0%, the authors are women in 87.5%, 44.0% of women direct theses. The scientific production of directors according to the H Index is very uneven, since one person has an index of 76 and another of 1. The temporal sequence of production is erratic, since in some years no Doctoral Theses are defended, but in 2017 were three. Conclusions: Spanish research in clinical Doctoral Theses on gender is scarce. It would be desirable to develop doctoral programs that promote the generation of theses in health that have gender differences in health care as their central point.
Keywords: 
Subject: Public Health and Healthcare  -   Other

1. Introduction

Health with a gender perspective is not frequent nowadays in Health Sciences Degree studies (Segovia-Saiz et al., 2020; Valenzuela V. et al., 2019). It entails a series of risks and dangers, that are more evident in healthcare for women. Biases are constantly committed in this area and are difficult to detect if one is not concious of the issue (Sánchez-Recio et al., 2021). According to Sara Velasco, women have specific pathologies which need specific responses (Arias, 2008). Given the differential morbidity of women, the Health System opts to create specific women's health programmes based on reproductive aspects but leaves out the rest of the care. In many case, the symptomatology and the course of the illnesses, as well as the needs that must be addressed, are different. Equity in healthcare for women would be achieved through political, social and healthcare measures, for which academia must to justify their adoption through research (Koch-Gromus & Gromus, 2014; MacIntyre & Hunt, 1997).
Determining the scientific and research production on gender within the framework of Health Sciences is a relevant issue to show the scarcity of scientific and technical material within this field and, therefore, its impact on the perpetuation of biases in women's healthcare (Alonso-Arroyo et al., 2010; Ballarín Domingo et al., 1995).
Most frequently, scientific work is carried out in the form of journal articles, as well as the review of the scientific literature based on bibliometric databases. This production analysis is frequently performed at national and international levels. A simple search in the Web of Science database makes it easy to check. Despite this, there is one product of gender research, the Doctoral Thesis, which is not usually taken into account (Aladro Vico et al., 2014).
The aim of this study is to analyse Spanish Doctoral Theses on gender in Health Sciences defended in Spain from 1976 to 2022, according to review and evaluation criteria.

2. Materials and Methods

In this research, the productivity indicator is achieved through of the quantification of Doctoral Theses retrieved in TESEO (Ministry of Universities, 2022) or “Fichero central de Tesis Doctoral de España”, taking into account the University where the Doctoral thesis is defended, the branch of knowledge to which the doctoral programmer belongs or the students who study it, the subject of the doctoral thesis, whether it is a doctorate man or doctorate woman , the director or directors and the scientific production of the person who directs the Doctoral Thesis. The search is also carried out with a conceptual criterion such as the UNESCO code [320100] - CLINICAL SCIENCES (UNESCO, 2022). To complete this search from a conceptual view, the term "gender" is incorporated both in the title and in the abstract as a simultaneous advanced search, since there is no code assigned to the word gender or any other related word within the TESEO thesaurus (Ministry of Universities, 2022).
A total of 57 Doctoral Theses are obtained, of which 17 are selected. The rest are rejected because they refer to the genus of microorganisms and not to the human genus. Subsequently, one of them is discarded because it is a very old Doctoral Thesis and it is not possible to obtain access. Finally, 16 Doctoral Thesis are rescued and included in the study. All the Doctoral Theses are analyzed by consensus of two experts who, according to the content of the title and abstract, accept or reject them for this research. Each expert makes his or her assessment individually and then resolves the discrepancies in pairs until an agreement is reached.
The productivity indicators are the University where the doctoral thesis is defended, the branch of knowledge, the subject of the thesis, whether it is a doctoral thesis and supervisor, scientific productivity of the supervisor. The scientific production of the supervisor is analyzed based on the author H-Index (University of Valladolid, 2022), which is located in the Scopus database (Elsevier, 2022b) by searching through the name and surname of the persons who supervise the Doctoral Theses.
The sample size is all Doctoral Theses listed in the TESEO database. Those related to Clinical Sciences and included the word gender in their title or abstract are selected. In total, there are 17 Doctoral Thesis, but as mentioned above the sample size is 16 Doctoral Theses in the cases in which it is necessary to have data that are only in the Doctoral Thesis itself and could not be retrieved.
The statistical analysis has been carried out by numerical descriptive (frequencies, percentages) and graphical (bar chart, maps and time series). An annual time series has been created from 1997 to 2020 because there are no Doctoral Theses on this subject outside this range. In this series, the 17 Doctoral Theses referring to gender are included, as it is recognized that those not found are also scientific production in the subject of study. A predictive model of scientific research in Doctoral Thesis format for the next 24 years in Spain has also been generated according to a Holt-Winters model. The programmer used was Excel®.
In accordance with Spanish legislation, the study does not require the approval of an Ethics Research Committee, since neither humans nor animals are involved in the research.

3. Results

The following are patterns related to the indicators mentioned in the methodology section, analyzed in the 16 or 17 theses retrieved, depending on each case.

3.1. Scientific production by Universities

The Doctoral Theses defended correspond to eleven Universities. The values according to frequency of the Doctoral Theses defended can be seen in Figure 1. It is worth noting that the range of the Doctoral Theses defended in these Spanish Universities varies from one to three, with the highs number in the Complutense University of Madrid. This University has a feminist research institute (INSTIFEM)) (Universidad Complutense de Madrid, 2022c) which runs a multidisciplinary PhD programmer in gender.
In terms of scientific production by regions, six of the Doctoral Theses have been defended in the Autonomous Community of Madrid, at the Complutense University of Madrid, the Autonomous University of Madrid and the University of Alcalá. It is not surprising that the country´s capital is the city where most Doctoral Theses are defended since it has more Universities than other Spanish regions. It is striking, however, that only one gender-related Doctoral Thesis has been defended in the Balearic Islands. These University is limited in the number of students but it contributes with a Doctoral Thesis. Other regions, such as Castilla y León with hundreds of years old Universities, do not have any Doctoral Theses defended on gender in health (Figure 2).

3.2. Scientific production by branch of knowledge

Gender studies are multidisciplinary studies in the vast majority of Spanish Universities. This situation means that these studies are associated with a Faculty or Department not related to the subject of the Doctoral Thesis. So this analysis in multidisciplinary studies is not a reliable solution.
Clinical sciences specified in the UNESCO code as [320100] (UNESCO, 2022) encompass a wide range of health branches. These health branches show the medical specialties, but not the health degrees generated by the health professions listed in Law 44/2003, of November 21, of the organization of health professions (Government of Spain, 2003). This law establishes the health professions with University Degrees: Medicine, Pharmacy, Dentistry, Veterinary Medicine, Nursing, Physiotherapy, Occupational Therapy, Podiatry, Optics and Optometry, Speech Therapy and Human Nutrition and Dietetics, as well as the specialties in health sciences derived from them. In this study, only Doctoral Theses belonging to Medicine, Nursing, Physiotherapy or Midwifery (Nursing specialty) are defended. Most of the Doctoral Theses (n=12; 75%.0) correspond to the medical branch (Figure 3).
Gender studies are broad and multidisciplinary. Determining what specific aspects are being studied in Universities about gender allows for knowing the concerns of the researchers and the lines of research they may be pursuing (Table 1). As expected, gender violence is the most studied topic. It is relevant that the aspects that produce gender inequality in research achieve a high score in scientific production. On the other hand, male sexuality is the least studied in these Doctoral Theses, and it is referred to men who have sex with men when it is studied.

3.3. Sex of the doctoral student and thesis supervisor

It would be desirable to measure scientific production based on the gender of the person writing the Doctoral Thesis. In the database TESEO, the biological sex associated with a male or female name is the only item consulted, so this is the criterion followed. The number of women who have defended their Doctoral Thesis about gender in health sciences is 14 (87.5%), compared to 2 men (12.5%).
Referring of Doctoral Thesis supervision and taking into account that the same Doctoral Thesis can be supervised by more than one researcher, a total of 25 people are obtained, of which 11 (44.0%) are women and 14 (56.0%) men.

3.4. Gender-related scientific output of the thesis supervisor

There are many ways of analyzing the scientific output of a researcher. One way is through the H-Index of the Scopus database (Elsevier, 2022b). Another way may be to determine the number of Doctoral Theses supervised individually. This last criterion is not commonly used, whereas the H-Index is widespread.
The Scopus database (Elsevier, 2022b) contains references and citations from the publisher Elsevier (Elsevier, 2022a), which collects the most studies in health sciences. It also collects studies of high scientific quality.
The H-Index is an author impact metric. It is a system created by Jorge Hirsch in 2005 to measure the professional quality of scientists based on the number of citations their articles receive (Gisbert & Panés, 2009). To calculate this index, the scientific articles are ordered from the highest to the lowest number of citations received. The H-Index is the number in which the number of citations coincides with the number of citations of an article. The H-Index of the persons who supervise health Doctoral Theses on gender ranges from 1 to 76, which is a very wide range. The mean is 17.32, which is a significant value (Figure 4). To preserve the anonymity of the Doctoral Thesis supervisors, a random number has been assigned to them for the graphical representation of this analysis.
The pattern found shows a not accelerated and discontinuous growth, with 17 Doctoral Theses defended in 23 years. The Holt-Winters model (Mira Segura et al., 2018) is calculated to predict the scientific production in this field over the next 24 years using the Excel® programmer, including a value ⲁ of 0.3 and 𝛽 of 0.3. The model presents seasonality in terms of thesis production, being close to 1 thesis per year, as can be seen in Figure 5.

4. Discussion

This study is necessary because no code in TESEO allows finding Doctoral Theses based on gender directly, highlighting this need. In recent years, feminist activism has increased notably worldwide and in Spain (Ackerly, 2021; Balaguer Callejón, 2019; Campbell & Wasco, 2000), so the absence of gender-related Doctoral Theses may be due to this fervour has not translated into a simultaneous advance in the academy or that the TESEO database does not classify gender Doctoral Theses on health in a way that makes their search more intuitive.
The number of Doctoral Theses during a long period of 23 years is limited. Any other health topic has higher numbers over the same time. For example, the subcode 3201.01 Clinical Oncology has 2385 records in TESEO database or 3201.05 Clinical Psychology has 1405 (Ministry of Universities, 2022). These two subcodes are included in the category Clinical Sciences. Perhaps gender is not as attractive to universities as other aspects.
Universities that encourage the creation of spaces of equality in both the relational and teaching aspects could have a greater number of Doctoral Theses related to gender and health (Balaguer Callejón, 2019). Undoubtedly, those Universities with a specific doctoral programmer in gender and health science degrees are the most likely to have defended Doctoral Theses on gender. For example, the Complutense University of Madrid, where the most gender-related health Doctoral Theses have been defended (Complutense University of Madrid, 2022a), has two master's degrees related to gender issues (Complutense University of Madrid, 2022d), several health sciences degrees (Complutense University of Madrid, 2022b) and a cross-cutting doctoral programmer in gender. Gender institutes or gender chairs within the university can also encourage Doctoral Theses on this subject (Shai et al., 2021) (Izquierdo & García, 2015). Logically, Universities with these characteristics are located in large cities where student demand is high. So it is not at all surprising that Madrid is at the forefront. Indeed, not only the available resources that are important but also the social structure and the symbolic imaginary of the population in a region. In autonomous communities where the government is more inclined towards progressive tendencies, gender-related Doctoral Theses are more likely to be defended, as was the case in Zaragoza during such a mandate (Díaz Orueta et al., 2021).
The vast majority of Doctoral Theses defended are in Medicine is not a coincidence. The hegemony of the medical degree over other health sciences degrees is not new (Niezen & Mathijssen, 2014). Since very ancient times, respect for the figure of a male doctor was owed, regardless of his conduct. This situation has generated an empowerment of the profession and an aura of superiority based on advantages in the field of research, which is financed by pharmaceutical laboratories in many cases in exchange for pharmacological prescriptions (Ñique-Carbajal et al., 2021; Piccirillo et al., 2019). Nurses, physiotherapists, and midwives have not had access to the support provided to doctors and, in addition, the chances of success in competitions for funding research projects is lower in these professions than in the case of Medicine (Muñoz García & Muñoz García, 2019). Nursing carries out qualitative studies more frequently as it seeks to resolve or respond to human needs beyond the figures and understanding the dynamics of the experience that people have. Generally, the rankings of scientific evidence either forget to include qualitative studies or place them at the end with the least demonstrated evidence and, therefore, the lowest recommendation of their results (Brewin, 2016). Nursing is a feminized science and this does not help it to be at the forefront (Nogueira et al., 2022). Its oldest speciality, midwifery, does not escape from these biases either. In addition to being a feminized profession, the object of study tends to be exclusively women, which further discredits the profession (Allotey, 2011). On the other hand, it is very striking that interest in research with a gender perspective is shown, which indicates progress an elimination of inequalities in research with men and women. Even more striking is that a Doctoral Thesis on men in relationships with men is classified as a gender Doctoral Thesis. Although gender studies usually focus on women, Universities are increasingly addressing health in LGTBI+ (lesbian, gay, trans, bisexual, intergender and beyond) groups (Grant et al., 2021).
The fact that 87.5% of doctoral students are female does not translate into similar figures when the analysis of female thesis supervisors is performed, who account for only 44,0%. Although women in Spain achieve doctoral studies more frequently than men (González-Alcaide & González-Teruel, 2020), academic success does not translate into interest in an academic career in healthcare, or else they encounter gender-related obstacles that make it more difficult for them to access Doctoral Thesis supervision than men. More research is needed to demonstrate this hypothesis.
in the Doctoral Theses analyzed, the most frequent subject matter is gender-based violence, which is not unpredictable, as the general population's sensitivity to this issue has increased considerably (Escribà-Agüir et al., 2010). Despite this, the numbers of murders of women are far from falling or disappearing in this country (Ministry of Equality, 2022). The population's concern is transferred to the academic sphere to provide an answer to what is happening in the street. Differences in physical aspects of a specific disease is another subject that has been studied extensively, since the classic biomedical model only considers the women as exceptions to men's health and disease (Castejón Bellmunt, 2022). It is in them that the appropriate levels of drugs are investigated, or the symptoms of a disease are defined (Estany & Casacuberta, 2021).
Although the H-Index may not be the best way to determine the scientific production of a researcher, it is the most widely used in health sciences, and one of the most specifically refers to the Scopus database. The presence of a researcher in the scientific circle depends on his/her H-Index (Francisco José García-Peñalvo et al., 2019). Supervising a thesis does not depend exclusively on this factor, as there are authors with a very low H-Index (1) who supervise Doctoral Theses. A debate has arisen about the relevance of the H-Index. It seems that this index does not influence too much in the tutoring process of doctoral theses, which is the highest rank in Spanish Universities. It is assumed that those who carry out the tutoring functions should be the people best prepared to do so. This study does not provide any answers but opens up a new line of research.
The timing of the Doctoral Theses for 23 years shows a dysfunctionality in the homogeneity of annual production since in some years no Doctoral Theses are defended, but, for example, three have been defended in 2017. The Holt-Winters model indicates a prediction for the next 24 years based on around one annual gender-related health Doctoral Thesis defended in Spain. This data shows a scarce production if it is compared to other health subjects, as already indicated (Ministry of Universities, 2022).
Like any research study, this one has several limitations. The first of these is the lack of absolute reliability in that Doctoral Theses recovered are the only ones defended in Spain on the object of study, as there is no UNESCO code for gender studies. Also, the impossibility of making categorical statements decontextualized from the moment and the social context based simply on data from an archive.
However, there are positive aspects of the research, as it allows us to identify people who can act as a lobby in Doctoral Theses, are often in Doctoral Thesis supervision, sit on Doctoral Thesis boards and publish very frequently on gender and health. Knowing this phenomenon helps to demystify health studies with a gender perspective and may encourage new female researchers to carry out their Doctoral Theses on this subject since, except for the lobbyists, the rest are health professionals like themselves.
The door is left open for future researches that are interested in finding results with the methodology of this study in other countries. In addition, it could provide answers to questions that cannot be answered with this study. This is the case of identifying whether the criteria followed in Spanish universities for supervising and tutoring doctoral theses are adequate and whether these lobbies exist, as is suspected.

5. Conclusions

Spanish research on clinical Doctoral Theses on gender is quite limited compared with other subjects in the clinical sciences. This fact means that the differences and inequalities in health care between men and women are not studied, extending this problem of inequality in clinical practice to the academic sphere.
In Spain, the promotion of doctoral programmers covering gender inequalities in health is necessary, since the data show the scarcity of Doctoral Theses on gender and health. Perhaps, the impetus should come from undergraduate studies in the field of health and should be encouraged, especially in the categories that study gender the least, with a view to their future doctoral studies. Similarly, greater sensitivity is needed in Spanish Universities for the creation of doctoral programmers related to health and gender, as well as lines of research in this area.

Author Contributions

For research articles with several authors, a short paragraph specifying their individual contributions must be provided. The following statements should be used “Conceptualization, R.M.C.G. and I.C.G.; methodology, R.M.C.G. and C.D.F.; software, R.S.C.; validation, R.M.C.G., S.N.P. and E.O.; formal analysis, R.M.C.G.; investigation, L.P.P.; resources, M.A.M.F.; data curation, R.M.C.G.; writing—original draft preparation, I.C.G.; writing—review and editing, R.S.C.; visualization, L.P.P. and E.O.; supervision, M.A.M.F. All authors have read and agreed to the published version of the manuscript.” Please turn to the CRediT taxonomy for the term explanation. Authorship must be limited to those who have contributed substantially to the work reported.

Data Availability Statement

The data of this research can be found in the TESEO database (https://www.educacion.gob.es/teseo/irGestionarConsulta.do).

Conflicts of Interest

The authors declare no conflict of interest.

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  41. Valenzuela V., A. , Cartes V., R., Valenzuela V., A., & Cartes V., R. (2019). Perspectiva de género en la educación médica: Incorporación, intervenciones y desafíos por supercar. Revista Chilena de Obstetricia y Ginecología, 84(1), 82–88. [CrossRef]
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Figure 1. List of Spanish Universities producing Doctoral Theses in health sciences with a gender perspective.
Figure 1. List of Spanish Universities producing Doctoral Theses in health sciences with a gender perspective.
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Figure 2. Map of Spain in terms of the production of Doctoral Theses on gender in health by regions.
Figure 2. Map of Spain in terms of the production of Doctoral Theses on gender in health by regions.
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Figure 3. List of branches of knowledge in the health sciences producing Doctoral Theses on gender.
Figure 3. List of branches of knowledge in the health sciences producing Doctoral Theses on gender.
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Figure 4. List of branches of knowledge in the health sciences producing Doctoral Theses on gender.
Figure 4. List of branches of knowledge in the health sciences producing Doctoral Theses on gender.
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Figure 5. Predicted annual graphical pattern of the production of clinical health doctoral theses on gender in 24 years since 2020.
Figure 5. Predicted annual graphical pattern of the production of clinical health doctoral theses on gender in 24 years since 2020.
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Table 1. Ordered list of gender themes according to the number of theses that study them.
Table 1. Ordered list of gender themes according to the number of theses that study them.
Subject of the doctoral thesis Number of thesis
Gender violence
Physical pathology
Gender and health inequality research
Tobacco
Immigrant women
Women's history
Male sexuality		 4
3
3
2
2
1
1
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