Eliza A. Hawkes, MBBS Hons, FRACP, DMedSc
Carla Casulo, MD
Gender diversity, equity, and inclusion (DEI) in medicine has long been acknowledged as more than “the right thing to do,” with clear evidence of benefits in innovation, collaboration, and workplace culture.1 Yet the data continue to showcase challenges in achieving these goals despite women comprising 50% of the population, and furthermore, 50% of medical graduates in most developed countries since the early 2000s.
In our own field of lymphoma, the metrics remain concerning. The formation of our international Women in Lymphoma (WiL) group in 2019 was driven by the existence of all-too-familiar
male-only panels, speaker rosters, and authorship, as well as underrepresentation of women in leadership positions. Despite an extensive pool of outstanding female scientists and clinicians and diversity policy implementation from leading journals such as The Lancet and Cell, we chart how fewer than one-third of invited lymphoma authors at top journals are women.2 This low female representation is replicated in data collated by WiL from most major conference steering committees and invited speakers despite women consistently comprising 50% of attendees.3 The minority of first, or senior, female authors presenting original lymphoma research at recent international conferences also demonstrates diminished opportunities.
There have been some wins. First, female leaders have been celebrated at prestigious journals and organizations such as Blood, Blood Advances, the British Society for Haematology, ASCO, the American Society of Hematology (ASH), the European Society for Blood and Marrow Transplantation, and the National Cancer Institute.
However, the need to continue to celebrate such milestones highlights the large task ahead. The rapid growth of WiL to 1,000 members, (10% male), from 56 countries in only 4 years emphasizes the desire and need for change. WiL has created a network ranging from junior faculty to global female lymphoma talent at the top of their game across six continents. WiL’s free online career development sessions showcase consistently that women in academic medicine still have the same stories to tell: family planning questions during employment interviews, being overlooked for opportunities because they “didn’t come forward” or were thought to be “too busy with family,” being the only “token” female present, being interrupted and talked over, having stated ideas being immediately repeated or reexplained by men to the room at advisory boards or steering committees, and far worse.
“Quotas in isolation are not successful at achieving sustainable gender parity and can pose the risk of women falling from ‘glass cliffs,’ where the role is set up for them to fail.”— Eliza A. Hawkes, MBBS Hons, FRACP, DMedSc, and Carla Casulo, MD
Tweet this quote
Although not universal, the overwhelming experience of women internationally remains one of underrepresentation and discrimination at all levels. This experience is confirmed by data. The 2023 United Nations (UN) Gender Social Norms Index report demonstrated an alarming 9 of 10 people globally (men and women) holding biases against women.4 Society judges identical characteristics in leaders differently according to gender; women are three times more likely than men to receive feedback regarding negative “aggressive” communication styles and criticized for behaviour considered a leadership credential when demonstrated by a man.5 Female job candidates are judged on more criteria than men for the same role.6 In addition, women are socialized from early childhood to behave in ways that make them less likely to seek advancement and self-promotion.
Many examples of discrimination are unintentional, with most the result of unconscious, multifactorial, and often systemic bias. This is why the enormous energy by organizations devoted to “fixing women” with leadership courses that teach “more successful” leadership behavioral models hasn’t worked. In fact, implementing DEI training and feedback to leadership is the least effective way of affecting change because the bias is unconscious.7
So, How Do We Achieve Gender Equity?
“Unless we actively and intentionally include women, the system will unintentionally exclude them.” —Elizabeth Broderick, AO, Champions of Change Coalition founder and UN Special Rapporteur for discrimination against women
WiL joins the chorus of advocacy groups demanding we “fix the system.” Fixing the system requires improved recognition of bias coupled with multifaceted organizational and individually motivated change and analysis of the data leading to and supporting change. Evidence-based approaches reducing unconscious bias to achieve gender parity already exist.8,9
Moving the ‘Unconscious’ to the ‘Conscious’: Addressing Bias
Decision-making related to recruitment and talent identification is influenced by commonly themed biases including:
- Affinity bias—where people are chosen for attributes similar to those of the decision-maker
- Halo effect—where the person is liked by decision-makers, so all their traits and skills are viewed favorably
- Confirmation bias—seeking to confirm beliefs, preferences, or judgments and ignore contradictory evidence
- Social bias—where individuals agree with the majority, or a senior colleague, to preserve harmony.
WiL advocates for disruption to systems that permit these biases to continue unchecked.
Both implicit and explicit attitudes about DEI can change over time with active disruption.10 Organizations must continue to acknowledge and test the status quo. Review and dismantling of every aspect is required to install role-based policies and talent selection processes that incorporate transparency and flexibility at all levels.
A recent major disruption causing mixed results was the COVID-driven flexible modes of work and communication using available technology. These adaptations increased the engagement of women in education, with attendance at major international conferences such as ASH, ASCO, and the American Association for Cancer Research soaring to record numbers because of virtual options—but additional familial care pressures decreased women’s research output. These contrasting results demonstrate the complexity of a desire to engage but a need for resources for women to contribute.
‘You Cannot Be What You Cannot See’: The Thorny Subject of Quotas
“I’m sometimes asked when will there be enough [women on the supreme court]? And I say when there are nine; people are shocked. But there’d been nine men, and nobody’s ever raised a question about that.”—Ruth Bader Ginsburg
Quotas in isolation are not successful at achieving sustainable gender parity and can pose the risk of women falling from “glass cliffs,” where the role is set up for them to fail. However, quotas do improve diversity of engagement, reduce bias, and have not demonstrated a decrease in academic output quality.
Arguments regarding diluting quality of talent or lack of qualified women to engage do not stand up. Our WiL leadership regularly draws on its own 1,000-member talent pool and has identified no shortage of expert speakers for nine meetings in our online “WiLing Wednesdays” educational series between 2019 and 2023; there have been 40 sessions and panel discussions exclusively delivered by more than 120 women, ensuring junior faculty representation within each topic. Furthermore, a special WiL issue commissioned by Haematological Oncology (the official journal of the International Conference on Malignant Lymphoma) included 10 reviews written exclusively by more than 65 female authors. Reviewers’ feedback included “excellent review by noted experts in the field” and “a must-read for all trainees.”
“For the immediate future, WiL and others continue to collaboratively advocate, analyze, and motivate the global academic and clinical organizations to achieve gender equity in medicine.”— Eliza A. Hawkes, MBBS Hons, FRACP, DMedSc, and Carla Casulo, MD
Tweet this quote
WiL’s Industry Working Group engages pharmaceutical companies to highlight the very low female leadership in academic collaborations and applauds recent industry initiatives addressing the quotas of women involved. AstraZeneca’s “HERmatology” program has committed to 50% of invited trial lead investigators, ad board attendees, panelists, and company-selected speakers being women by 2025. The Working Group also addresses gender inequity within industry.
Additionally, the WiL “panel commitment” initiative (https://womeninlymphoma.org/about-us) adopted from the Champions of Change Coalition panel pledge expects both female and male members and affiliates to commit to participation only in panels with adequate gender balance and publicly promote the inclusion of women in relevant forums, where potential systemic biases have not permitted equal opportunity.
Mapping Metrics Changes the Metrics
“If you don’t know where you’ve come from, you don’t know where you are going.”— Maya Angelou
Accountability is a proven key component to effective organizational change.8 As scientists, we hypothesize based on assumptions and are often surprised by our results because our initial assumptions were subject to bias and thus incorrect. When organizations and the public can see where the bias is, change is instituted much more successfully.
Organizations with poorly transparent, or absent, accountability strategies are woefully behind. One major international general medical journal in our recent published analysis had only a single female author of a review article in the past 5 years (3%).2 Professional educational organizations with no gender targets or published gender data continue to advertise events with a minority, or no, women speakers.
In academic publishing, tracking inclusion data for editorial positions, peer review, and assignment of published articles is a step some journals have already taken. Larger conferences hosted by organizations such as ASH and ASCO insist on diversity at the core of their Educational Committee responsibilities, and the data demonstrate this strategy is working. WiL continues to map metrics related to academic presentations, publications, education, and research leadership, but the onus of publishing these metrics should not remain on advocacy groups such as WiL.
Where to? The Future of Course!
Our true hope is that advocacy groups like WiL become redundant because the systems we rely on for academic and clinical leadership acknowledge and address the barriers to gender equity fostered by unconscious bias. Like all good research causing change, any attempt that is collaborative and transparent is not in vain, even if it individually fails.
Organizations that optimize the use of the full gender talent pool available are already proving to be more successful in their goals. For the immediate future, WiL and others continue to collaboratively advocate, analyze, and motivate the global academic and clinical organizations to achieve gender equity in medicine.
DISCLOSURE: Dr. Hawkes has received grants, personal fees, and other compensation from Roche; grants and personal fees from Bristol Myers Squibb/Celgene; grants from Merck KgA; grants, personal fees, and other compensation from AstraZeneca; personal fees and other compensation from Merck Sharpe & Dohme; other compensation from Gilead Sciences; personal fees and other compensation from Janssen; other compensation from Antigen; other compensation from Novartis; other compensation from BeiGene; personal fees from Regeneron; and personal fees from Specialised Therapeutics. Dr. Casulo has served as a consultant and received honoraria from Mashup Media, BMS, AbbVie, and Genentech; has received research funding from Genmab, Gilead, and Genentech; and has served in a leadership role for the FL Foundation and the American Society of Hematology.
REFERENCES
1. Fine C, Sojo V: Women’s value: Beyond the business case for diversity and inclusion. Lancet 393:515-516, 2019.
2. Hawkes EA, Trotman J, Casulo C, et al; International Women in Lymphoma Steering Committee: Author gender representation of journal reviews and editorials on lymphoma (2017–2022). Lancet 402:523-525, 2023.
3. Trotman J, LaCasce A, Osborne W, et al: Women in Lymphoma: A 4-year journey in promoting gender equity. Hematol Oncol. May 25, 2023 (early release online).
4. United Nations Development Programme: 2023 Gender Social Norms Index. Available at https://hdr.undp.org/content/2023-gender-social-norms-index-gsni#/indicies/GSNI. Accessed September 29, 2023.
5. Correll SJ, Simard C: Research: Vague feedback is holding women back. Harvard Business Review. April 29, 2016 (digital article).
6. Moscatelli S, Menegatti M, Ellemers N, et al: Men should be competent, women should have it all: Multiple criteria in the evaluation of female job candidates. Sex Roles 83:269-288, 2020.
7. Kalev A, Dobbin F, Kelly E: Best practices or best guesses? Assessing the efficacy of corporate affirmative action and diversity policies. America Sociology Review 71:589-617, 2006.
8. Mousa M, Boyle J, Skouteris H, et al: Advancing women in healthcare leadership: A systematic review and meta-synthesis of multi-sector evidence on organisational interventions. EClinicalMedicine 39:101084, 2021.
9. Boulware LE, Corbie G, Aguilar-Gaxiola S, et al: Combating structural inequities: Diversity, equity, and inclusion in clinical and translational research. N Engl J Med 386:201-203, 2022.
10. Charlesworth TES, Banaji MR: Patterns of implicit and explicit attitudes: IV. Change and stability from 2007 to 2020. Psychol Sci 33:1347-1371, 2023.
Dr. Hawkes is the Lymphoma Lead at the Olivia Newton John Cancer Research & Wellness Centre, Austin Health, and Associate Professor in the Lymphoma and Related Diseases Registry, School of Public Health & Preventive Medicine at Monash University, Melbourne, Australia. Dr. Casulo is Associate Professor of Medicine and Assistant Director of Cancer Research Training and Education at the Wilmot Cancer Institute, Department of Medicine, University of Rochester Medical Center, Rochester, New York.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
