Abstract
While two editorials have raised concerns about the decline in Australian academic psychiatry, for a genuine rejuvenation to ever occur, we will need to re-examine how women can be better included in this important endeavour. While attainment of fellowship has reached gender parity, academic psychiatry has disappointingly lagged, with 80% of its senior leadership roles across Australia and New Zealand still held by men, with a similar situation in the United Kingdom and the United States as well as many other countries. Encouraging women into academic psychiatry is not only critical to progress as a profession but also will help address the current blindness to sex differences in biological psychiatry, as well the social impact of restrictive gender norms and the effects of gender-based violence on mental health. This potentially creates opportunities for significant gains and insights into mental disorders. However, addressing the barriers for women in academia requires tackling the entrenched disparities across salaries, grant funding, publications, teaching responsibilities, keynote invitations and academic promotions alongside the gender-based microaggressions, harassment and tokenism reported by many of our female academics. Many women must grapple with not just a ‘second shift’ but a ‘third shift’, making the burden of an academic career unreasonable and burnout more likely. Addressing this is no easy task. The varied research in academic medicine reveals no quick fixes, although promoting gender equity brings significant potential benefits. Areas such as academic psychiatry need to recognise our community’s growing discomfort with workplaces that choose to maintain status quo. Gender equity must be a critical part of any quest to revive this important area of practice for our profession.
As raised in recent Australian editorials, there has been a crisis in academic psychiatry, making this an ‘endangered’ area (Henderson et al., 2015; Suetani et al., 2022). However, while there has been a decline in opportunities for male academic psychiatrists, for women it is unclear there ever was a heyday from which extinction could be threatened. Women are no longer a minority in psychiatry, yet a career in academic psychiatry remains, for many women, at best aspirational and is often beyond reach. Furthermore, by not addressing barriers specifically for women in academic psychiatry, there is a risk of losing the hearts and minds of many talented potential future researchers and leaders.
Where are women in academic psychiatry in 2022? The first appointment of a woman as a Professor in Medicine in Australia was in 1960, followed by the first Professor of Psychiatry, Beverley Raphael in 1978 (McGorry, 2019). Winifred Boys-Smith became New Zealand’s first woman Professor of Science in 1911, but it was not for another 80 years that a woman – Sarah Romans – became a Professor of Psychiatry in 1993. Professors Raphael and Romans were inspiring vanguards, mentoring and supporting men and women and championing research across diverse areas of mental health including women’s mental health. However, as reported in a recent discussion paper on gender equity and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) (www.ranzcp.org/membership/gender-equity) despite this early leadership and the intervening decades, current RANZCP data show only 1.8% of female members have attained associate professor or professorship (vs 6.1% for men) and 80% of senior academic leadership roles across Australia and New Zealand continue to be held by men. These numbers reported in the discussion paper are despite admission to fellowship in psychiatry reaching close to parity more than a decade ago. When we examine data in the United Kingdom and the United States, while women are starting a career in academic psychiatry, their progression to senior roles is no better. It has been reported that there has been no increase in numbers of women reaching Professor of Psychiatry in the United States since 1980, and between 2013 and 2018, there was a drop in the number of women Professors of Psychiatry (Borlik et al., 2021; Sheikh et al., 2018). In the United Kingdom, data reported found that while 35% of members of the academic faculty within the Royal College of Psychiatrists were female, they represented only 10% of Professors (Dutta et al., 2010). The question is: why does academic psychiatry struggle to engage with women and what benefit would there be to academic psychiatry should this be addressed?
Barriers at the starting gate
Under the current RANZCP training structure, for most aspiring academics, the timing of this is following their fellowship, which for many women inevitably coincides with life events such as pregnancy, parental leave and primary caring responsibilities for young children. For all aspiring clinical academic psychiatrists, the time required to obtain a PhD and build a track record comes at least partially from personal time (variously referred to in the literature also as leisure time). However, data show that women will have on average 8 hours less personal time a week than men, and the gender gap is the greatest in families with young children (Sayer et al., 2009; Syrda, 2021). While there has traditionally been an unequal gender division of household labour that typically increases with children, it was anticipated that as women worked and earned more, this would be automatically corrected. However, a recent study drawing on data from 1999 to 2017 found that women continue to do significantly more housework (Syrda, 2021). While for couples without children, this is independent of women’s income, for those with children and against prediction, women’s housework increases for women with higher incomes (Syrda, 2021). A recent study examining the impact of COVID found while childcare hours increased for Australian men, there was no change in men’s housework hours leaving an ongoing unpaid workload discrepancy for women (Craig and Churchill, 2021). These barriers arise through this need to balance work and home commitments. There is also the issue of coincidental timing, as there is a simultaneous need to devote significant time to building an academic career while at this time in life is also when many women choose to start families. This is noted as a significant factor in the poor retention of women in early academic psychiatry careers in the United States and the United Kingdom (Borlik et al., 2021; DeLisi, 2021; Dutta et al., 2010; Sheikh et al., 2018). Furthermore, these are also similar issues highlighted across gender equity in all academic medicine (Coe et al., 2019; D’Armiento et al., 2019).
What is only starting to be considered is the ‘mental load’ that is a disproportionate burden for women and particularly those with children (Dean et al., 2022). The mental load is defined as both the cognitive and emotional labour associated with family life, this includes planning, scheduling and organising family needs and tasks, as well as the feelings of care and responsibility for meeting the variety of needs of a family (Dean et al., 2022). This is frequently an invisible and unaccounted aspect of the ‘second shift’. Unlike housework, it is carried across the day and roles and frequently encroaches on time and focus for other roles such work or study. However, mental load still requires research into how to quantify this if there is to be a consideration of this further burden and barrier in workplace policies (Dean et al., 2022).
The overall emerging picture these data and research suggest is an almost impossible situation for many women early career psychiatrists and particularly for those who have young children, requiring many of those women to undertake a ‘third shift’ of building academic credentials in almost non-existent personal time if they wish to pursue an academic career. While family life is not the only factor, it is no surprise that burnout in the medical profession is higher for women, although data specifically on women in academic psychiatry are absent (Templeton et al., 2019).
For many women, during this critical early career period, this presents a stark choice: to continue to try and build the track record required to get a foot in the door by undertaking this ‘third shift’ and leaving almost no personal time; or to place their faith in the flawed and seldom genuinely applied dimensions of ‘career disruption’ and ‘relative to opportunity’ such as in national research fellowship and funding schemes (Barnett et al., 2022). A recent commentary has termed this loss of women at the beginning of their academic career as the ‘Bermuda triangle’ as it is not explained in terms of interest or capacity, rather it suggests unchartered issues around structural inequities that fail to account for the caregiving commitments, as well as the gender bias that often assigns women to roles weighted towards teaching rather than research (Reiser et al., 1993). In addition, the gender pay gap in academia, in addition to the discrepancy in pay between clinical and academic roles, likely contributes to loss of female psychiatrists from academia (Catenaccio et al., 2022). This has been noted in many countries including Australia, New Zealand, the United Kingdom and the United States, across academic medicine, and is not fully accounted for by academic level (Borlik et al., 2021; Brower and James, 2020; Dutta et al., 2010).
Myth of meritocracy
Attempts to introduce initiatives to support women to make it over the starting line into a career in academic psychiatry and indeed across academic medicine are often challenged by the idea that a system based on meritocracy will inevitably prevail over time to correct any gender imbalance. In a commentary published in 1991 on women in Australian and New Zealand psychiatry, Carolyn Quadrio highlighted the persistent and disappointing gender imbalance in keynotes and speakers at conferences (Quadrio, 1991). Yet, sadly, this was echoed in a later paper published in 2015, where author and psychiatrist Penny Golding reported at the 2014 RANZCP Congress, there was one woman keynote speaker (Golding, 2015; Quadrio, 1991). Since 2009, at least 75% of keynotes at RANZCP Congress have been males, and only 1 year was parity reached. Likewise, the majority of academic grants and awards have been to males, and the
A meritocratic approach focuses on a masculinised model of success, emphasising factors such as hierarchy and competitive achievement (Pritlove et al., 2019). This can, for some women, contribute to further inequity due to a preference for working in a more collaborative manner. Additionally, women who excel in a masculine environment can be criticised for not behaving in a conventionally female manner. This leads to a double bind for female academics who may be disadvantaged for either embracing or challenging the meritocratic approach (Pritlove et al., 2019).
In progressing a successful academic career, it was traditionally ‘publish or perish’ while there has been a move away from this, the value placed on
Further barriers: tokenism, harassment and microaggression
While opening the door into an academic career has many hurdles for women, there continues to be unique challenges once women are established within academic psychiatry careers. These include barriers to career progression but also involve the daily experiences of respect and inclusion. Likewise, for many women, there may be struggles with ‘imposter syndrome’ providing a further barrier (Borlik et al., 2021). An Australian commentary on women in psychiatry outlined the toll in both morbidity and distress of working in male-dominated institutions, the impact of toxic masculine cultures, the experiences of misogyny and harassment as well as the devaluing of differences that women might bring to academia (Quadrio, 1991). These reflections are echoed from women in Canada, the United Kingdom and the United States (DeLisi, 2021; Dutta et al., 2010; Pattani et al., 2018). Women report the persistent use of incorrect titles, scheduling of department activities at times not compatible with additional caregiving responsibilities, being talked over and ignored in meetings and devaluing areas of research that focus on issues that predominantly either impact women or attract greater number of women researchers (Files et al., 2017; Lewiss et al., 2020). Across academia, there is also the experience of being assigned the ‘department housework’ such as cleaning and food rosters, organising social events or roles associated with pastoral care, teaching and mentoring of students (Ashencaen Crabtree and Shiel, 2019). Furthermore, in a survey, 54% of female medical academics reported sexual harassment and as movements such as #metooSTEM and #TimesUpHealthcare emerge, this is likely to underestimate, rather than overestimate, the extent of this issue for women (Raj et al., 2020). The emphasis for changing this situation is too often placed on the individual woman to ‘lean in’ and independently forge her career in academia, minimising the responsibility of institutions and leaders (Lewiss et al., 2020). While many women experience barriers to being ‘at the table’, anecdotally women report the converse can occur in some departments, where the rush to ensure virtue signalling and gain advantage in any affirmative action initiatives in grants or publications, lead to their required inclusion to demonstrate diversity, however, instead suggesting tokenism rather than real engagement in gender equity (Borlik et al., 2021).
Intersectionality: when gender, ethnic and other inequalities combine
The 2020 Women in the Workplace report (Thomas et al., 2021) highlights the particular difficulties for women who are ‘onlys’, the sole person of their race or gender in the room at work, as well as acknowledging the significant barriers faced by women with disabilities. ‘Onlys’ stand out and tend to be more heavily scrutinised and subject to negative stereotypes (Thomas et al., 2021). Being an ‘only’ for one dimension of identity is challenging enough. But ‘double onlys’ – women of colour, women with disabilities or women with traditionally marginalised identities – face even more bias, discrimination and pressure to perform or to ‘represent’ and become more likely to experience burnout. This has, by some, been termed a ‘minority tax’, reflecting the burden in time and additional duties that these ‘double onlys’ can face (Borlik et al., 2021). This may be particularly true for Aboriginal and Torres Strait Islander and Māori women psychiatrists who face the double barriers of institutional racism
The role of organisations and cultural change
A survey of RANZCP fellows examining the factors that influenced women to take up research found that protected time, seeing women in senior research positions and an institution that supported their research including through affirmative action initiatives were all significantly associated with women undertaking research, whereas having a supportive mentor was not (Favilla and Bloch, 2004). This may suggest the relative greater importance of structural solutions and sponsorship as much as mentorship in paving the way for women to take up and continue careers in academic psychiatry and futhermore the importance of organisation-led initiatives in doing this. The survey also noted working part time or having time off for family reasons was significantly less common in women who undertook research. While this finding is not surprising, given the challenges already outlined in balancing being a primary caregiver to young children and progressing an academic career, if not addressed, this would render the loss of many of the potential female academic workforce in psychiatry. However, a more recent study in academic medicine has found that women are both less likely to seek sponsorship and also less like to be perceived by senior academics as a potential protégé (Levine et al., 2021). Furthermore, across academic medicine, top down rather than bottom up approaches are found to be more successful (Laver et al., 2018). A recent study found that implementations of important programmes that systematically address gender inequity across academia, such as Athena SWAN, can in fact also have unintended results of reproducing and reinforcing gender inequity, particularly if the burden of implementation falls to female academic staff without the wider organisation and cultural change (Caffrey et al., 2016). However, organisations do benefit greatly from external views, such as Athena SWAN, rather than relying entirely on internal processes that risk being subject to ongoing unconscious bias.
Addressing the barriers is no easy task and what is clear from the varied research in academic medicine reveal no easy or quick fixes. Unfortunately, to date, there have been no areas of academic medicine that have made substantial progress in the progression of women in academic careers to Professor, Deans or Department Chairs (Nguyen et al., 2022). Any interventions need careful evaluation to ensure they do not inadvertently increase inequity; they cannot be focused on the individual alone to fix this situation and what is very clear is organisational commitment and leadership are essential whatever approaches and interventions are trialled (Caffrey et al., 2016; Laver et al., 2018; Mousa et al., 2021). The Global Health 50/50 report (https://globalhealth5050.org/2021-report/) identified specific global recommendations for gender equity that included (1) an organisational public statement on gender equity, (2) gender equity policies and principles within broader policies and (3) reporting on sex disaggregated data. These are all achievable in academic psychiatry both through RANZCP and within research institutes and departments of psychiatry. Many medical colleges and departments of academic medicine, both in Australia and around the world, have statements and action plans for achieving gender equity. Ensuring the RANZCP as well as departments of psychiatry embraces this goal also would be an important first step. A recent systematic review on healthcare leadership strategies also provides a range of important targeted approaches including understanding the role of quotas, mentorship programmes as well as specific programmes to address gaps for women in academia, such as in early career fellowships where there has been career disruption, as well as the importance of supporting part-time leadership roles (Mousa et al., 2021).
Indeed, across academic psychiatry and medicine more broadly, commentaries call for fairly consistent changes. These include leadership and accountability for change, identifying implicit bias including in the use of language, creation of part-time leadership roles that might be shared, developing role models, the role of allyship by senior males, ensuring data are available, proactive policies that address recruitment, retention and promotion of women, sponsorship programmes, investment in early career women and ensuring through quotas balanced numbers in committees, keynotes, editorships and other aspects of academic life (Coe et al., 2019; D’Armiento et al., 2019; DeLisi, 2021; Dutta et al., 2010; Mousa et al., 2021; Sheikh et al., 2018). Ensuring that programmes to address gender equity are inclusive of all those who identify as women as well as women within the broader LGBTQIA+ community is critical to progressing any agenda of inclusion as well as bringing important perspectives to research (Borlik et al., 2021). Furthermore, in the current pandemic, it is even more important that academic psychiatry considers the increased burden of unpaid work for women and the clear impacts on productivity including publication output (Andersen et al., 2020; Craig and Churchill, 2021). While the pandemic has brought some advantages in workplace flexibility, overall it appears to have widened the gap for women seeking academic careers both directly through loss of opportunity and productivity and also indirectly through increasing the burden of the second shift (Craig and Churchill, 2021; Woitowich et al., 2021). Finally, it is critical that areas such as academic psychiatry recognise the growing discomfort in our community among professional women with workplaces remaining status quo.
Can a sex and gender perspective rejuvenate psychiatric research?
The benefits in bringing gender equity into academic psychiatry will not only benefit the individual woman and her aspirations but also bring a fresh perspective from diverse representation which has the capacity to transform our research agenda and approaches for all academic psychiatrists. Sex and gender are a missing lens from much of the psychiatric research undertaken. Yet, sex and gender are significant drivers of the burden of health and health inequality worldwide including for mental health (Shannon et al., 2019; Shansky and Murphy, 2021). From conception, there are sex differences in the foetus, placenta and early development that potentially inform vulnerability and resilience to later mental health conditions, as well sex differences in timing of onset, presentation and response to many of our treatments for mental disorders (Hartung and Lefler, 2019; Howard et al., 2017; Zucker and Prendergast, 2020). In spite of that all of our major diagnoses and understanding of psychopathology, most of our proposed aetiological models and clinical trials of psychopharmacological treatments are sex neutral in approach (Hartung and Lefler, 2019; Howard et al., 2017).
Like understanding sex differences, ensuring principles of gender equity inform both our research
Conclusion
Failure to leverage the talent pool embedded in half of the discipline will make it much harder for the profession to meet our collective academic challenges and social responsibilities. Our blindness to sex differences in biological psychiatry, as well as our under-appreciation of the social impact of restrictive gender norms and experiences of gender-based violence on mental health, risks us failing to realise the opportunities for significant gains and insights into mental health disorders. Furthermore, by not addressing the stark gender inequities experienced by women renders the area potentially not just endangered but Jurassic. Addressing gender equity in academic psychiatry is critical in the quest to revive this important area of practice for our profession.
Footnotes
Declaration of Conflicting Interests
The author(s) 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: M.B. is supported by a National Health and Medical Research Council (NHMRC) Senior Principal Research Fellowship (1156072). D.S. is supported by an NHMRC Emerging Leadership Level 2 Fellowship (1194635). S.B.H. is supported by an NHMRC Investigator Grant (1178666).
