Do gender and racial differences exist in letters of recommendation for obstetrics and gynecology residency applicants?

Published:September 07, 2021DOI:


      Studies in several fields demonstrate gender and racial differences in descriptions of applicants in letters of recommendation. However, gender and racial biases in obstetrics and gynecology residency letters of recommendation are understudied.


      This study aimed to determine whether there are differences in the letters of recommendation written for medical students applying for obstetrics and gynecology residency based on applicant gender and underrepresented in medicine status.

      Study Design

      We analyzed all letters of recommendation submitted to a single obstetrics and gynecology residency program during the 2019–2020 application cycle using a computerized text analysis software to evaluate the presence of 25 word categories. Multivariable regression was used to compare differences in the frequency of word categories by gender and underrepresented in medicine status. Concurrently, we performed a qualitative content analysis of letters from a random sample of applicants balanced for gender and underrepresented in medicine status and explored emerging themes until thematic saturation was reached.


      We analyzed 3060 letters written for 834 applicants, 721 (87%) of whom were women and 198 (24%) of whom were underrepresented in medicine. Men authored 1605 letters (53%). There was no difference in word categories used in letters written for men and women applicants on multivariable analysis. Similarly, there was no word category difference between letters written for applicants who were underrepresented in medicine compared with White and Asian applicants. However, women letter writers used more communal (relationship-oriented) words compared with men letter writers (P<.001). Moreover, on the qualitative analysis of letters from a random sample of 30 applicants, comments about personality traits were frequent in all letters. Comments on surgical skills, work ethic, and leadership were found more in letters for White and Asian applicants, and phrases that were doubt raisers were found more in letters written for underrepresented medicine applicants.


      On linguistic analysis, letters of recommendation written for obstetrics and gynecology residency applicants were similar overall compared with applicant race and gender.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Iqbal I.J.
        • Sareen P.
        • Shoup B.
        • Muffly T.
        Attributes of successfully matched versus unmatched obstetrics and gynecology fellowship applicants.
        Am J Obstet Gynecol. 2014; 210: 567.e1-567.e8
        • National Resident Matching Program
        Results of the 2018 NRMP Program Director Survey. 2018.
        (Available at:)
        • Grimm L.J.
        • Redmond R.A.
        • Campbell J.C.
        • Rosette A.S.
        Gender and racial bias in radiology residency letters of recommendation.
        J Am Coll Radiol. 2020; 17: 64-71
        • Turrentine F.E.
        • Dreisbach C.N.
        • St Ivany A.R.
        • Hanks J.B.
        • Schroen A.T.
        Influence of gender on surgical residency applicants’ recommendation letters.
        J Am Coll Surg. 2019; 04: 356-365.e3
      1. Association of American.
        Medical Colleges Physician specialty data report 2019. 2019; (Available at:) (Accessed Sept. 16, 2021)
        • Galvin S.L.
        • Parlier A.B.
        • Martino E.
        • Scott K.R.
        • Buys E.
        Gender bias in nurse evaluations of residents in obstetrics and gynecology.
        Obstet Gynecol. 2015; 126: 7S-12
        • Hill E.K.
        • Blake R.A.
        • Emerson J.B.
        • et al.
        Gender differences in scholarly productivity within academic gynecologic oncology departments.
        Obstet Gynecol. 2015; 126: 1279-1284
        • Hofler L.G.
        • Hacker M.R.
        • Dodge L.E.
        • Schutzberg R.
        • Ricciotti H.A.
        Comparison of women in department leadership in obstetrics and gynecology with those in other specialties.
        Obstet Gynecol. 2016; 127: 442-447
        • Boatright D.
        • Ross D.
        • Connor P.
        • Moore E.
        • Nunez-Smith M.
        Racial disparities in medical student membership in the Alpha Omega Alpha Honor Society.
        JAMA Intern Med. 2017; 177: 659-665
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.
        Int J Surg. 2014; 12: 1495-1499
        • Association of American Medical Colleges
        Underrepresented in medicine definition. 2004.
        (Available at:)
        • French J.C.
        • Zolin S.J.
        • Lampert E.
        • et al.
        Gender and letters of recommendation: a linguistic comparison of the impact of gender on general surgery residency applicants✰.
        J Surg Educ. 2019; 76: 899-905
        • Lin F.
        • Oh S.K.
        • Gordon L.K.
        • Pineles S.L.
        • Rosenberg J.B.
        • Tsui I.
        Gender-based differences in letters of recommendation written for ophthalmology residency applicants.
        BMC Med Educ. 2019; 19: 476
        • Pennebaker J.W.
        • Chung C.K.
        • Frazee J.
        • Lavergne G.M.
        • Beaver D.I.
        When small words foretell academic success: the case of college admissions essays.
        PLoS One. 2014; 9e115844
        • Kacewicz E.
        • Pennebaker J.W.
        • Davis M.
        • Jeon M.
        • Graesser A.C.
        Pronoun use reflects standings in social hierarchies.
        J Lang Soc Psychol. 2014; 33: 125-143
        • Newman M.L.
        • Pennebaker J.W.
        • Berry D.S.
        • Richards J.M.
        Lying words: predicting deception from linguistic styles.
        Pers Soc Psychol Bull. 2003; 29: 665-675
        • Cohn M.A.
        • Mehl M.R.
        • Pennebaker J.W.
        Linguistic markers of psychological change surrounding September 11, 2001.
        Psychol Sci. 2004; 15: 687-693
        • Ross D.A.
        • Boatright D.
        • Nunez-Smith M.
        • Jordan A.
        • Chekroud A.
        • Moore E.Z.
        Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations.
        PLoS One. 2017; 12e0181659
        • Kobayashi A.N.
        • Sterling R.S.
        • Tackett S.A.
        • Chee B.W.
        • Laporte D.M.
        • Humbyrd C.J.
        Are there gender-based differences in language in letters of recommendation to an Orthopaedic Surgery Residency Program?.
        Clin Orthop Relat Res. 2020; 478: 1400-1408
        • Filippou P.
        • Mahajan S.
        • Deal A.
        • et al.
        The presence of gender bias in letters of recommendations written for urology residency applicants.
        Urology. 2019; 134: 56-61
        • Messner A.H.
        • Shimahara E.
        Letters of recommendation to an otolaryngology/head and neck surgery residency program: their function and the role of gender.
        Laryngoscope. 2008; 118: 1335-1344
        • Powers A.
        • Gerull K.M.
        • Rothman R.
        • Klein S.A.
        • Wright R.W.
        • Dy C.J.
        Race- and gender-based differences in descriptions of applicants in the letters of recommendation for orthopaedic surgery residency.
        JB JS Open Access. 2020; 5: e20.00023
        • Association of American Medical Colleges
        Physician specialty data report. 2021.
        (Available at:)
        • Go C.
        • Lang S.
        • Byrne M.
        • Brucha D.L.
        • Parviainen K.
        • Sachdev U.
        Linguistic analysis of letters of recommendation for vascular surgery and obstetrics and gynecology applicants detects differences in attributable strengths based on gender.
        J Surg Educ. 2021; 78: 1535-1543
        • Friedman R.
        • Fang C.H.
        • Hasbun J.
        • et al.
        Use of standardized letters of recommendation for otolaryngology head and neck surgery residency and the impact of gender.
        Laryngoscope. 2017; 127: 2738-2745
        • Rojek A.E.
        • Khanna R.
        • Yim J.W.L.
        • et al.
        Differences in narrative language in evaluations of medical students by gender and under-represented minority status.
        J Gen Intern Med. 2019; 34: 684-691
        • Hoffman A.
        • Grant W.
        • McCormick M.
        • Jezewski E.
        • Matemavi P.
        • Langnas A.
        Gendered differences in letters of recommendation for transplant surgery fellowship applicants.
        J Surg Educ. 2019; 76: 427-432
        • Sudol N.T.
        • Guaderrama N.M.
        • Honsberger P.
        • Weiss J.
        • Li Q.
        • Whitcomb E.L.
        Prevalence and nature of sexist and racial/ethnic microaggressions Against surgeons and anesthesiologists.
        JAMA Surg. 2021; 156e210265
        • Teherani A.
        • Hauer K.E.
        • Fernandez A.
        • King Jr., T.E.
        • Lucey C.
        How small differences in assessed clinical performance amplify to large differences in grades and awards: a cascade with serious consequences for students underrepresented in medicine.
        Acad Med. 2018; 93: 1286-1292
        • Mocanu V.
        • Kuper T.M.
        • Marini W.
        • et al.
        Intersectionality of gender and visible minority status among general surgery residents in Canada.
        JAMA Surg. 2020; 155e202828