Unleashing talent in mental health sciences: gender equality at the top

Summary

Society is undergoing a shift in gender politics. Science and medicine are part of this conversation, not least as women's representation and pay continue to drop as one progresses through more senior academic and clinical levels. Naming and redressing these inequalities needs to be a priority for us all.

Declaration of interest

None.

2018: a suffrage centenary, #MeToo and gender pay gaps

2018 is the centenary of women's suffrage in the UK. This sits in the contemporary landscape of the #MeToo movement, debate on the persisting gender pay gap and representation of women at board level. Where are we in science, medicine and psychiatry? A recent podcast recorded at the Royal College of Psychiatrists hosted academics, clinicians and policy advisors discussing work by Carter et al ¹ on women in academic environments. That paper noted how women were less likely than men to ask questions at seminars and conferences. It opened podcast conversations on participants’ reflections and perceptions of this, and the related ethos and culture of their employers.

This matters enormously. Women were described as ‘literally less visible’ by Carter and colleagues, and it appears to map onto career progression. Women are continuing to outnumber men at tertiary education, but only in more junior positions. In Europe, across all academic subjects they account for: 59% of undergraduates, 47% of PhD graduates, 45% of fixed-term contract postdoctoral researchers, and 37% of junior and 21% of senior faculty positions. In the UK, women account for a fifth of overall professorship and head of institution positions. The issue is particularly problematic in STEM subjects (science, technology, engineering, and mathematics), where women have historically been under-represented; Hewlitt et al ² found that leave rates for women in these subjects peak about 10 years into their careers. Within academic medicine, the picture has been improving over the past decade, though there is variation by specialty. Primary care has the highest rate of women clinical academics (about 46%); at about 30%, psychiatry is not the worst (surgery is), but just about sits in the top half, above radiology and below paediatrics.³

Senior academic, clinical and managerial under-representation: an end-game of less pay

The academic output of women has been shown to be less often cited, and they suffer from underrepresentation in authorship. A recent paper in Nature found an inverse relationship between journal impact factor and women who were either first or last author.⁴ It is not clear which factors are at play; there are the aforementioned issues of fewer women in senior academic positions, but also concern about reviewer bias. There is mixed evidence about the effects of double blind reviewing, and concern that even with such measures authors can often be identified.

In clinical life in the UK we see a similar picture. Over half of foundation doctors are women, dropping to 36% at consultant level; at 43% this is somewhat better specifically in psychiatry, and this represents an increase of 3% over the last 5 years. However, this figure hides considerable variation between clinical subspecialties: women make up about 37% of consultants in Forensic psychiatry, whereas within child and adolescent mental health this climbs to approximately 64%. It is important to note that non-training, non-consultant grades make up 24% of medical workforce within psychiatry, where women continue to be over-represented at 54%.⁵ This report does not include linked data on ethnicity. Given the known impact of intersectionality on women's opportunities this missing data is clearly crucial for further research in identifying areas for targeting policy. We know that psychiatry relies heavily on international medical graduates, 65% of whom are Black and Minority Ethnic (BME). General Medical Council data show 37% of the overall psychiatry medical workforce are from BME backgrounds. Full equality by numbers (forgetting whole time equivalents) is estimated to take another two decades. In primary care, women account for more than 50% of the workforce, but only 16% of CCG Chairs. The ‘leaky pipeline’ persists, with reducing women representation with seniority in terms of career progression, resulting in a loss of talent and diversity, a loss to the individuals concerned and a loss to academic and clinical institutions.

In management and leadership roles, implicit and explicit bias may be an issue with different attributes and skills frequently ascribed to men and women. In evaluations and reference letters, the language used is often less favourable to women's natural abilities,⁶ who are frequently lauded for their ‘hard work’ rather than their ‘brilliance’. It has been argued that women more commonly take on ‘less rewarded’ roles such as sitting on committees, having organizational responsibilities, mentoring others and teaching. These duties receive less acknowledgement and take time away from other important areas, hindering promotion.⁷ The truth remains that even in 2018, women are far more likely to take on a ‘double shift’ – having the bulk of domestic responsibilities as well as a professional life.

Differences are also reflected in pay. Across the whole NHS there is an overall pay gap of 8.6% in favour of men; amongst doctors this is even wider, women earning an average 34% less, which has expanded over the last decade. This year, the BBC reported on how 95 of the 100 highest earning doctors in the UK are men, with full-time consultants earning on average £14 000 more than women in equivalent positions. Some of the contributing factors to these figures are well recognized, including higher rates of flexible training, part-time working and subsequently additional time required to attain higher positions. However, fewer women are applying for, and receiving, clinical excellence awards (CEAs). Data for this vary locally, but it has been proposed as one of the drivers to change the existing award scheme. Interestingly, this does not appear to be as pronounced for local CEAs in academia, with approximately equal percentages of men and women holding them. However far fewer women in academia held national CEAs - just under a quarter, compared with over 40% of men – though, importantly, they were equally likely to be successful at attaining one when they applied.³ Women appear not to be putting themselves forward for these awards: at the very top of the scale, six and a half times more men than women have a platinum award.

Next steps: the right thing is the best thing – unleashing talent

What should we be doing about this as a profession? Awareness of the issues, measuring, benchmarking and challenging them, and looking for mechanisms for local redress are a start. The Athena SWAN charter is noteworthy in higher education for supporting institutes in improving measures of equality, such as progression of students into academia, career journeys of staff and the work environment. Within the Royal College of Psychiatrists, respect is a defined key organizational value which includes challenging inequality. To ensure that a commitment to narrowing the gaps in gender equality runs through all college policy, the College has recently appointed its first Associate Dean for Equality, Diversity and Inclusion.

There are recognized criteria for good leadership, including targeting leadership biases which can allow departmental or organizational evaluation to ensure an environment that encourages women's leadership to flourish. An example is the Aurora Leadership Scheme that promotes exposure, mentoring and meaningful management opportunities. Those in senior positions – men as well as women – have particular responsibilities and means to support the next generation of diverse talent to reach the top. We have seldom had so many medical Royal Colleges – including our own – led by women, and both our current National Mental Health Director and previous National Clinical Director for Mental Health have high visibility. The President of the Royal College of Physicians, Professor Jane Dacre, is leading an independent review into the gender pay gap for doctors that will keep this conversation alive.

However, there are limits to what any organisation can achieve, until more fundamental societal causes of inequality are addressed. Men are a crucial part of this conversation; for too long many men saw inequity as a ‘women's issue’ – it is a societal issue including welfare policy and cultural attitudes and practices in terms of child care and part-time working.⁸ Other intersectional issues can scarcely be done justice in a single editorial, but we are reminded that only 2% of professors in the UK are female and from BME backgrounds. Goldin⁹ argued that the largest advance to career attainment gap in the labour market is to improve temporal flexibility. Changes in how jobs are structured, with more flexibility in work hours, and less reward for working long hours might help. Indeed, this is one of the key pillars of Nordic policies for gender equality which, alongside investment in gender equal workplaces and free childcare, have contributed to creating some of the most gender-equal labour markets.

Equality is not just about having a level playing field, it is about unleashing talent. As well as being the ‘right thing to do’, the aforementioned Nordic model has been shown to have contributed considerably to economic growth, re-emphasizing the societal loss from inequity. Work by the Center for Creative Leadership (CCL), the primary community of leading and emerging women entrepreneurs and executives in Silicon Valley,¹⁰ has shown that greater senior female leadership improves perceived line management support, employee engagement and organisational dedication, whilst reducing staff burnout.

We finish by throwing a couple of challenges to the BJPsych and the academic publishing sector. Firstly, we would welcome a review of the processes and commitments toward female representation on publication and in leadership positions. Secondly, a quick look at the stats show that most journals still have unequal representation of women at editorial board level. Looking at the New England Journal of Medicine, Nature, Annual Review of Psychology, JAMA psychiatry and the BMJ, between 22 and 50 percent of editorial boards are female. To adopt another of 2018's hashtags, as #immodestwomen we say that's better than it was a decade ago, but not good enough. We hope that the BJPsych, with about a third of women on the board, will lead the way in creating equality.