ARTHRITIS & RHEUMATISM Vol. 52, No. 3, March 2005, pp 697–706 DOI 10.1002/art.20881 © 2005, American College of Rheumatology SPECIAL ARTICLE Women in Academic Rheumatology Ingrid E. Lundberg,1 Seza Ozen,2 Ayse Gunes-Ayata,3 and Mariana J. Kaplan4 by presenting a historical, social, and cultural perspective of this situation in different parts of the world. We therefore investigated the proportion of female and male faculty members and professors in academia in general (Table 1) and in rheumatology in particular (Table 2) in some selected countries. A striking similarity was found among most countries worldwide, with an average of ⬃10–15% of full professors in general academia being women (Table 1) (1,2); in rheumatology, the overall situation is similar, except that there is a slightly higher percentage of women, an average of ⬃20%, among full professors (Table 2). For purposes of illustration, we have provided more complete data from a few countries in Europe, Latin America, North America, and Asia. We devote extra interest to the situation in Turkey, a country that is culturally traditional, predominantly Muslim, and much less developed than its Western counterparts, but has better female representation in all areas of academic life, including medicine, than most European countries. We contend that this is due to the affirmative action policies implemented by the founders of the Republic, and in this respect, such an approach could be considered for possible emulation by other countries. Introduction In the scientific program of the meeting of the European League Against Rheumatism (EULAR) in Lisbon in June 2003, only 16% of ⬃144 chairperson positions were held by women. This proportion was much the same at the EULAR meeting in Berlin in June 2004, with a distribution of 19% female chairpersons. A slightly higher but somewhat similar proportion was seen at the 2003 meeting of the American College of Rheumatology (ACR) in Orlando, in which ⬃26% of the chairpersons were women. In most of the scientific meetings in the rheumatology field, there appears to be an overwhelming majority of male academicians among the chairpersons and keynote speakers. These observations raise some questions regarding the impetus of this male predominance. Do these numbers reflect a significant gender difference in scientific activity in more general terms, and in academic positions in the field of rheumatology specifically? Moreover, is the predominance of men in academic rheumatology a reflection of a more general phenomenon in academic medicine? Does a gender difference among rheumatology professors reflect the female:male ratio among physicians in general or rheumatology specialists in particular, and does it reflect the female:male ratio among medical students or graduate students? Finally, and most important, is this a problem? The purpose of this report is to stimulate discussion on the status of women in academic rheumatology Europe When the first universities opened in Europe in the twelfth century, they were, with few exceptions, open for men only. Prior to this, higher education in Europe took place in monasteries or cloisters, where both women and men were educated (3). With the opening of universities, educational opportunities for women definitely narrowed and it was not until the end of the nineteenth century that most European countries opened their academic institutions to female students and female teachers. The situation for women in Europe can be exemplified in more detail by the situation in Sweden, which is in many ways representative of other European countries, although there are regional differences (1,2,4). Supported by the Erik och Edith Fernström’s Foundation for Medical Research, Swedish Society of Medicine. 1 Ingrid E. Lundberg, MD, PhD: Karolinska University Hospital, Solna, and Karolinska Institutet, Stockholm, Sweden; 2Seza Ozen, MD: Hacettepe University, Ankara, Turkey; 3Ayse GunesAyata: Middle East Technical University, Ankara, Turkey; 4Mariana J. Kaplan, MD: University of Michigan Medical School, Ann Arbor. Address correspondence and reprint requests to Ingrid E. Lundberg, MD, PhD, Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, SE-171 76 Stockholm, Sweden. E-mail: Ingrid.Lundberg@medks.ki.se. Submitted for publication May 21, 2004; accepted in revised form November 29, 2004. 697 698 LUNDBERG ET AL Table 1. Woman professors among faculty members in academia overall* Country Year Full professor Associate professor Assistant professor Turkey Finland Portugal Australia France Spain United States Norway Canada Sweden Italy New Zealand Greece United Kingdom Iceland Israel Belgium (French) Denmark Ireland Austria Germany Switzerland Belgium (Flemish) The Netherlands 1996/1997 1998 1997 1997 1997/1998 1995/1996 2002 1997 1998 1997/1998 1997 1998 1997/1998 1996/1997 1996 1996 1997 1997 1997/1998 1999 1998 1996 1998 1998 21.5 18.4 17.0 14.0 13.8 13.2 13 11.7 12.0 11.0 11.0 10.4 9.5 8.5 8.0 7.8 7.0 7.0 6.8 6.0 5.9 5.7 5.1 5.0 30.7 NA 36.0 23.0 34.2 34.9 24 27.7 NA 22.0 27.0 10.2/23.5† 20.3 18.4 22.0 16.0 7.0 19.0 7.5 7.0 11.3 19.2 10.0 7.0 28.0 NA 44.0 40.7 NA 30.9 NA 37.6 NA 45.0 40.0 45.5 30.6 33.3 45.0 30.8 18.0 32.0 16.3 12.0 23.8 25.6 13.1 20.0 * Values are the percentage of women (see ref. 1). NA ⫽ information not available or not applicable to that country. † These values refer to the percentage of woman lecturers/associate professors. Sweden. Although medical education in Sweden has been open to both women and men since the 1870s, women were not allowed to work in hospitals and, by 1926, could only obtain jobs as private general practitioners (5). During the twentieth century, the percentage of female medical students increased, and for the last 20 years, the number of female and male students has been approximately equal. In recent decades, the percentage of women among students obtaining a PhD degree in medicine in Sweden has also rapidly increased; in 2002, 55% of the students who passed the qualifying examination for a PhD at the Karolinska Institutet, the major medical school in Sweden, were women. The first Swedish female physician, Karolina Widerström, graduated from medical school in 1888. Since then, the total number as well as the percentage of women among Swedish physicians has increased gradually, from 6% in 1930, to 18% in 1970, to 28% in 1980, to 42% in 2004 (6). Among rheumatology specialists, the percentage of women has increased at an even faster pace. Currently, there is an almost equal number of male and female rheumatology specialists in Sweden (46% female, as of January 2003), and in the training programs for rheumatology, 68% of the fellows are women (as of 2004). The first woman to be appointed full professor in Sweden was a physician, Nanna Svartz, at the Karolinska Institutet in Stockholm in 1937 (6). Interestingly, Dr. Svartz’s research was devoted to the field of rheumatology and she later became well known for her development of sulfasalazine to treat patients with rheumatoid arthritis. This late appointment of the first woman professor in Sweden could be explained by the laws and rules promulgated into the early twentieth century (as mentioned above), but those may not have been the only obstacles for women pursuing an academic career in Sweden. It took another 30 years for the second woman to be appointed full professor at Karolinska Institutet. Since then, the percentage of female professors at this university has increased slowly, and even today, women constitute only 16% of full professors, which also reflects the situation at other Swedish universities. In rheumatology, 22% of the full professors are women. Other European countries. Trends similar to those in Sweden have been noted in other European countries over the last century, since the universities opened their doors to women. The low percentage of women among professors in academia in general, as well as in the medical sciences and in rheumatology, is, with few exceptions, a common situation in most European WOMEN IN ACADEMIC RHEUMATOLOGY 699 Table 2. Number of professors in rheumatology and the percentage of women among them in Europe, Latin America, and the United States Professors in rheumatology Country Total no. % women Romania Finland Turkey* Brazil Mexico Hungary† United States‡ Sweden The Netherlands United Kingdom Denmark France Germany§ Italy Austria¶ Czech Republic# Norway Ireland Switzerland 8 2 62 50 43 41.3 34 25 25 22 20 18 16 5 4.5 4 0 0 0 0 0 Not available Not available 4 Not available 9 10 28 6 64 15⫹1/22 24 2 8 6 2 4 * Professors in internal medicine working within rheumatology. † 80% of practicing rheumatologists are women. ‡ Selected from 33 rheumatology programs. § In total, there are 22 professors in rheumatology of which 15 professors are department chairs and 1 is professor in experimental rheumatology. Among the 15 professors heading departments of rheumatology, there are no women; among all 22 professors, there is 1 woman. ¶ Professors in internal medicine and chairpersons of rheumatology departments. # Professors in internal medicine or pediatrics but working within rheumatology. countries (Tables 1 and 2). This is particularly striking at the levels of full professor, university presidents, and members of prestigious medical societies (2,7). There are only 2 member states in the European Union (EU), Finland and Portugal, in which there are more than 2 women for every 10 men among the top university staff, which is, in most countries, synonymous with the title of full professor. In 2001, the percentage of women among full professors was similar between the EU-associated countries (2). Among full professors within the EU in 2000, women comprised an average of 13.2% (2). For academic rheumatology, the numbers are not always comparable between countries. In some countries, rheumatology is not considered a separate specialty, but is, rather, included as a subspecialty within internal medicine (as in Austria and the Czech Republic) or pediatrics (as in the Czech Republic), but with special chair positions for rheumatology divisions (Austria). Furthermore, the academic levels are not always comparable between countries. Despite these uncertain- ties in the available data, the estimated percentage of women among full professors in rheumatology is slightly higher than the average number of women among full professors in science overall (Table 2). In pediatrics, there seems to be a higher percentage of women; however, definite numbers are not available because pediatric rheumatology is not recognized as a separate subspecialty in most European countries. North America Canada. In 1967, 11% of students entering medical school in Canada were female; this percentage increased to 62% in 1997 (8,9). In the field of rheumatology, a study published in 2001 (10) revealed equal representation of male and female rheumatology trainees. In the same study, as of 2000, there were 262 rheumatologists (139 in adult rheumatology, 23 in pediatric rheumatology) affiliated with academic units, and there was a predominance of men in the field, with a male:female ratio of ⬃2:1 (10,11). United States. Once standards for medical practitioners were established during the nineteenth century in the US, women had to fight strenuously for equal access to training and for respect in the practice of their profession (12). The first US woman physician was Dr. Elizabeth Blackwell, born in Britain in 1821. She studied medicine at Geneva Medical College in New York (13) and had to endure significant discrimination to be able to study and practice her profession. One way for women to fight such discrimination was the creation of allfemale medical schools. Boston (later New England) Female Medical College, founded in 1848, was the first medical school for women (12). In 1857, Dr. Blackwell established the New York Infirmary for Women and Children, the first American hospital staffed completely by women. By the end of the nineteenth century, 19 women’s medical colleges and 9 women’s hospitals had been established and women constituted 5% of American physicians. In 1889, fundraisers in the women’s movement offered the medical school at Johns Hopkins University an endowment of $500,000 on the condition that women be admitted on the same terms as men. In 1893, the school enrolled its first coeducational class and soon became a leader in providing opportunities for women (12). In the early twentieth century, most women’s medical colleges were closed due to the apparent belief that the battle for quality coeducation had been won. This contributed to a significant decrease in the number of woman physicians, since female enrollments to med- 700 LUNDBERG ET AL Table 3. Distribution of medical school faculty in the United States, by gender, rank, and department in 2003 Full professor Department Basic science Anatomy Biochemistry Microbiology Pathology—basic† Pharmacology Physiology Other basic science Total basic science Clinical science Anesthesiology Dermatology Emergency medicine Family medicine Internal medicine Neurology OB/GYN Ophthalmology Orthopedic surgery Otolaryngology Pathology—clinical† Pediatrics Physical medicine Psychiatry Public health Radiology Surgery Other clinical science Total clinical science Associate professor Assistant professor Men Women Men Women Men Women 78.5 84.9 80.3 80.4 84.7 86.5 82 82.4 21.5 15.1 19.7 19.6 15.3 13.5 18 17.6 71.8 71.3 70 67.6 78.8 76 65.3 71.5 28.2 28.7 30 32.4 21.2 24 34.7 28.5 67 69 67.4 58.1 66.4 67.6 63.3 65.5 33 31 32.6 41.9 33.6 32.4 36.7 34.5 87.5 83.2 90.7 78.3 88.5 88 86 87.8 97 92.1 82.4 78.75 78.3 83.6 76 87.3 94.5 79.7 85.5 12.5 16.8 9.3 21.7 11.5 12 14 12.2 3 7.9 17.6 21.2 21.7 16.4 21 12.7 5.5 20.3 14.5 75 59.8 78.8 68.8 77.3 76 69.8 76.9 88.8 83.1 68.5 62.4 61 70.3 60 77.1 87.2 61.7 72.4 25 40.2 21.2 31.2 22.7 24 30.2 23.1 11.2 16.9 31.5 37.6 39 29.7 40 22.9 12.8 38.3 27.6 66.8 54.8 72 55.3 64.4 64.7 49.2 68.7 85.3 71.7 61 47.1 58.5 54.8 48.7 69.8 80.4 46.4 62.2 33.2 45.2 28 44.7 35.6 35.3 50.8 31.3 14.7 28.3 39 52.9 41.5 45.2 51.3 30.2 19.6 53.6 37.8 * Values are the percentage, adapted from the Association of American Medical Colleges faculty roster (URL: www.aamc.org/data/facultyroster). OB/GYN ⫽ obstetrics and gynecology. † Some medical schools include pathology with basic science and others include it with clinical sciences. ical colleges were kept low and quotas existed in many of them. In addition, social pressure and the increase in allied health fields, such as social work and nursing, led to a decline in the women’s medical movement. Therefore, at the end of the 1940s, only 5.5% of students entering medical school in the US were women (13). It was not until after the women’s movement in the 1960s and the passage of Title IX of the Higher Education Act, which prohibits sex discrimination in federally assisted education programs, that the percentage of women attending medical schools and practicing medicine began to increase significantly (13). In 1967, 9% of the students entering medical schools in the US were women. For the academic year 2002–2003, 49% of medical school applicants and 49% of new entrants were female (14). Furthermore, the proportion of women in residency programs had grown to 38% by 2001 (15–20). In rheumatology, in the years 1987–1988, women accounted for 33% of all rheumatology fellows (21), and in August 2001, female rheumatology fellows accounted for 49.3% of the physicians entering adult rheumatology specialty training and 66.7% of the physicians entering pediatric rheumatology training (15). These percentages are significantly higher than those for other internal medicine subspecialties (21,22). Although the number of woman faculty members has increased since the 1970s (23), their proportion on medical school faculties has not increased as rapidly as in the student body. Indeed, a scarcity of women in leadership positions in academic medicine has persisted in the US despite their increasing numbers in medical training (24) (Table 3). In 2002, 29% of the entire faculty for all basic sciences and clinical sciences were women; they represented 24% of associate professors and 13% of full professors (24–35). Percentages of women in specific medical specialties are included in Table 3. No information is available regarding the percentage of academic positions that are filled by woman rheumatologists in the US. It is our understanding that the ACR is conducting a survey focusing on the WOMEN IN ACADEMIC RHEUMATOLOGY general health of academic rheumatology, but the response rate has been low and no information regarding the status of woman rheumatologists in academia is yet available (Miller A: personal communication). We selected 33 of the largest rheumatology programs in the US that included the names of their faculty members on their Web sites. We found that 25% of the faculty members in these programs were women. Regarding training programs in the US, 21% of rheumatology training program directors are women (36). Latin America In several Latin American countries, the proportion of women entering and graduating from medical schools is higher than 50%. The percentage of women at the faculty level varies between different countries, however. Although the academic systems in Mexico and Brazil are not quite comparable with those in Europe and the US with regard to the differentiation of positions at the professor level, we believe it is of interest to present the data on the status of women in academic rheumatology in these countries. Mexico. Women’s activity in science and medicine in Mexico was not well documented until the nineteenth century, at which time their situation changed and medical schools started to accept a few women (37). The first female Mexican physician, Matilde Montoya, graduated in 1887 (38), but it was only at the end of the 1960s that the percentage of female students in medical schools increased significantly (37,39). In 1967, women represented 18% of the medical students, while in 1987, 43% of medical students were women, and in 1998, 65% of the students registered at the Medical School of the Universidad Nacional Autonoma de Mexico, the largest university in the country and in Latin America, were female (39–41). Although the Mexican College of Rheumatology (formerly, the Mexican Society of Rheumatology) was founded in the 1940s, it was only after 1973 that the first woman entered this field (25). In 1998, a woman became president of the College for the first time (25). Nowadays, 38.5% and 30% of the members of the directive board of the Mexican College of Rheumatology and the Mexican Council of Rheumatology, respectively, are women. In 1975, 10% of the rheumatologists were women. Currently, from a total of 394 members of the Mexican College of Rheumatology, 36% are women. From a total of 10 rheumatology academic centers in Mexico, there are 59 academic rheumatologists, of whom 34% are women. 701 Brazil. The first Brazilian woman who graduated from a medical school was Maria Augusta Generoso Estrela (1860–1948). She received a scholarship from the emperor, Don Pedro II, and went to study medicine in New York, since women were not allowed to study in Brazilian universities at that time. She went back to Brazil in 1882, revalidated her diploma, and participated intensively in the medical field until her death. In a recent study published by the Conselho Federal de Medicina (CFM), 67.2% of physicians in Brazil were men and 32.8% were women between 1994 and 1996 (available at the CFM Web site at http: //www.portalmedico.org.br). However, among those physicians younger than age 35 years, 50% were women. These percentages have gradually been increasing. In rheumatology, the Sociedade Brasileira de Reumatologia registers 899 specialists in Brazil. Of those, 391 (43.4%) are women. According to data obtained from the Sociedade Brasileira de Reumatologia Web site, 41.3% of the rheumatology faculty members at universities and university hospitals in Brazil are women, and 20.5% of division/service chiefs are women (42). In the local chapters of the Sociedade Brasileira de Reumatologia, 50% of the presidents of these societies have been women (42). Other examples Japan. Women represent only 14.4% of all physicians in Japan. The rate of female medical graduates has increased recently and is now more than 30%. However, leadership positions in medical societies and medical schools are still dominated by an overwhelming majority of male physicians. Woman physicians hold an average of 4.1% of faculty positions in the 80 medical schools in Japan. Interestingly, the percentages appear to be lower in clinical specialties than in basic science, even in societies with high percentages of female members. Sugiura et al reported in 2000 that the number of professors in medical schools in Japan was 3,724 as of 1998, and women represented 1.7% of them (43). According to a survey from 2000, the total number of Board-certified rheumatologists in Japan was 2,830, and women represented 6.6% of them (44). Of the rheumatologists who hold positions in the Japanese College of Rheumatology Board, 2.8% (17 of 602 members) are women. Turkey. Since the first opening of Istanbul University in 1933, women have been allowed and even encouraged to enter medical school and to practice their profession. Between 1991 and 2003, the percentage of 702 female students has increased; for example, in the Medical School of Hacettepe University, the leading medical faculty in Turkey, the percentage of female students has increased from 40% to 45%. Female rheumatologists constitute 40% of the members of the National Rheumatology Society (45). At present, women occupy approximately onethird (37%) of the academic posts in Turkey (44). The majority are in humanities and fine arts, at a rate of 40–45%. However, the third preferred area for Turkish women in academics is the medical field (35%). In the last 10–15 years, there has been an increase in the percentage of women in all academic fields. As an example, in the Medical School of Hacettepe University, the percentages of faculty positions that were filled by women were 37% and 42% in 1991 and 2003, respectively. A similar trend has been present among the full professorships, increasing from 34% to 42% in the same time period. The percentage is similar among rheumatologists who hold an academic position, since 43% of the full professors in the departments of rheumatology in the 8 big Turkish universities are women (45). Discussion By presenting these data, we want to stimulate a debate on the situation of women in academic medicine and, in particular, in academic rheumatology. We are well aware that our opinion is based on our perspective as women in academic rheumatology in the US, Sweden, and Turkey and that our opinion is likely to present a biased view rather than a comprehensive assessment. Furthermore, there are uncertainties in the data presented. One major obstacle precluding a comprehensive review of the academic situation is that most countries do not have any official organization or institution that keeps records on the number of academic positions in different medical specialties and whether these positions are held by men or women. This information was available on the Web sites of the national rheumatology societies of some countries, but in most cases, this information was obtained by personal communication. Despite these limitations, we can conclude that although there are some regional differences in the organization of the academic structures, the academic situation for women is similar in most European countries, as well as across North and Latin America. Indeed, men far outnumber women among full professors in the field of medicine in general as well as in rheumatology, despite the almost equal numbers of women and men among medical students, rheumatology fellows, and LUNDBERG ET AL rheumatologists in recent decades. To understand the issues that may assist in developing remedies for the inequities that persist in many regions and across different cultures and countries, we selected certain nations within Europe, North America, and Latin America for our analysis. We also reviewed the situation in certain countries that have unique features due to the practices of past governments. We started our analysis with the situation among medical students. In most countries in Western Europe and in Latin and North America, the number of women and men entering medical school has been almost equal for decades. The number of women among physicians has increased vis-a-vis the higher number of women entering medical schools. The percentage of women among physicians varies between specialties. Interestingly, rheumatology appears to be a specialty that attracts women, and the number of women often equals the number of men among clinical rheumatologists and rheumatology fellows in many countries in Europe and the US. In some countries, such as Hungary, the proportion of woman rheumatologists is even higher (80%). However, although overt barriers to women in academic medicine greatly diminished during the twentieth century, it appears that the percentage of female faculty has not changed much in the last 2 decades, despite the increasing number of women entering medical school and the increasing number of women among physicians. In most countries in Europe and in North America, the “bottle neck” for women appears to be primarily at the associate professor and full professor levels (34,46–48). In some specialties, the absence of women in academic positions may be explained, at least partly, by the low number of women among the specialists, but this certainly could not be the explanation for the situation in rheumatology. Lack of extended family help, expensive child care, and short maternity leave periods are often cited as obstacles for career women, and it is certainly an important factor, particularly in the US where maternity leave periods are extremely short (and unpaid in many situations) compared with other countries (33,34,46,49– 53). This could not be the only explanation, however, since the inequity among faculty members in countries such as Sweden, where there has been a strong political movement to make child care available for everyone at a low cost, is not different from the rest of Europe or the US. The explanation is therefore uncertain. Although an extended maternity leave and available child care are helpful to encourage women to work outside their home, it is not the whole solution to promote women to higher academic positions. There are WOMEN IN ACADEMIC RHEUMATOLOGY studies from the US, Finland, and Norway in which the productivity and promotion rate among scientists from different fields, including biology and human science, were investigated in relation to gender, marital status, and having children. The investigators found that married women produced more scientific papers than unmarried women, and that women with children, at least those with children ages ⱖ10 years, produced as many scientific papers as or more scientific papers than those without children (54–56). These studies suggest that the female gender per se, rather than having a family, is a negative factor in making a scientific career (56,57). In contrast, the countries with the most equality among men and women in higher academic positions in rheumatology appear to be Turkey, Brazil, and Romania. Although the general situation in academics and in medicine in Brazil does not appear to be significantly different from other countries, there is a significantly higher proportion of women who hold academic positions and who are division chiefs in rheumatology. In Turkey, a country less developed than the rest of Europe, the US, and Japan, women have been more successful in reaching high academic positions. This was mainly due to a political attitude of the young Republic in the 1920s that took deliberate measures to involve women in professional life. The equal rights of citizenship were given to Turkish women at the instigation of Kemal Ataturk, the founder of the Turkish Republic. These measures recognizing the equal rights of women included the Civil Law in 1926 and the right to suffrage (vote); such measures were promoted prior to their appearance in many Western countries, including France. The aim of the new government of Turkey was to establish a modern and secular society through Westernization, which would greatly affect the status of women in Turkish society. Women’s higher education and career acquisition became a goal and the accepted norm for the middle- and upper-class elite families, and this was also facilitated by the government’s policies, which included introduction and support for women as role models, opening new secondary schools for girls, and scholarships for female students in the university. In fact, the Turkish case may be a good example of how political will and affirmative action can result in a significant change. In addition, the national policies promoting women’s upward mobility and empowerment through education could have contributed to the high percentage of women in academic medicine. An important factor that could also have contributed to the high percentage of women in academic rheumatology in Turkey may be the fact that some of the physicians who 703 funded rheumatology departments in the old metropolitan universities were women; this might have been an appealing factor, and these women may have served as role models for younger women in their decision to specialize in a given field. In Romania, the number of women exceeds the number of men among full professors in rheumatology. This is, however, not a general phenomenon in the medical sciences in that country, since other specialties are dominated by men (e.g., surgery). The highest academic positions, such as university presidents and deans, are all held by men. The explanation for the high percentage of women in academic rheumatology in that country is not clear. No affirmative action policies have been undertaken in Romania to promote women in science. Although salaries for academic positions as well as for physicians are relatively low, this may not be the whole explanation for the predominance of women in academic rheumatology, since holding an academic position is very prestigious in Romania. Notably, there is a clear predominance of women among employees in health care in general. In Japan, a country with strong cultural influences and practices, the situation is completely different. Japan is a country with very few women among physicians in general, and there are very few women holding faculty positions both in medicine in general and in rheumatology. Why do changes occur so slowly, particularly in North America and Europe? An often-proposed explanation for the underrepresentation of women within the highest academic positions is that they are underrepresented in academia overall, and also that they have entered scientific careers more recently; therefore, it is assumed that these differences will eventually disappear automatically. This may not be true, however. In Italy, a large group of senior investigators (78% men and 22% women) who started a position at the Italian National Research Council in 1988 were followed up for level of promotion 10 years later. Overall, 26% of the men but only 12.8% of the women had been promoted to top positions as research directors (7). A disparity in the advancement of men and women on medical school faculties was also recorded in the US in 2 cohorts between 1955 and 1985 (56) and between 1979 and 1997 (58). There is also a continuous loss of women from academic science (7,59). This appears to be a phenomenon that is present both in the US and in many European countries (60). Despite the fact that legal restrictions were lifted decades ago in most countries, 704 there may still remain subtle informal barriers within the social system of academic science, such as less access to strategic resources and social networks that are essential for career success (56). In this way, women may be less influential with regard to important decisions about the future of a research field or academic discipline (56). A crucial theoretical concept here is the “critical mass,” meaning, for example, that when woman scientists in a department or in a field have reached a sufficient number, they not only will have more opportunities to participate in the same way as men, but also will contribute to a change in attitudes and style in the department or in the field (56). There are also other informal barriers, such as cultural norms and gender role expectations and attitudes, that appear to limit women’s full participation in academia. In many countries in Europe as well as in North America, women have been encouraged to work outside the household for many years and participate in public life, but the traditional expectations on women to be responsible for the family and household still persist worldwide. Cultural or social attitudes and expectations on women and men naturally influence the choice of career (61). What could be done to achieve equal access to academic positions in medicine and rheumatology? Work from top academic institutions in the US has shown that unless clear steps are taken to improve recruitment and retention of women in academics, no significant changes in gender distribution in medical school faculty are expected throughout the entire twenty-first century (62–65). A study from Johns Hopkins University showed that specific interventions during a 5-year period resulted in substantial improvements in the development of women’s careers, and that an institutional strategy to this end can be successful in retaining women in academic medicine (66). These interventions included problem identification, leadership, and education of faculty. Furthermore, the study implemented strategies to improve faculty development, mentoring, and rewards to reduce isolation and structural career impediments. The implementation of these strategies showed that junior faculty women were retained and promoted, thus reversing previous experience, with a 5-fold increase in the number of women at the associate professor rank over 5 years (from 4 in 1990 to 26 in 1995). Furthermore, an interim 3-year followup study showed an increase of 183% in the proportion of woman faculty members who expected that they would still be in academic medicine in 10 years (from 23% [7 of 30] in 1990 to 65% [30 of 46] in 1993). One-half to LUNDBERG ET AL two-thirds of woman faculty members reported improvements in timeliness of promotions, manifestations of gender bias, access to information needed for faculty development, isolation, and salary equity (66). Women, more often than men, lack information about what is required for career advancement and receive less mentoring from senior faculty. Lack of mentoring is a difficult problem to resolve, but is of great importance since the pool of women from which to recruit academic leaders and role models for young women interested in academic medicine remains small (46–48,61,67–71). An interesting concept is the accumulation of advantages and disadvantages during the course of a scientist’s career, suggesting that even small differences that occur at an earlier stage in the scientist’s career may eventually lead to major outcomes, such as being invited as a speaker or chairperson for scientific meetings (56). Currently, the Association of American Medical Colleges has a Women in Medicine program that assists dean’s offices, woman liaison officers, and individual faculty in addressing gender-related inequities and improving the pathways for the contribution of women to academic medicine. In the US, the National Science Foundation announced in 1989 that it would give financial support to only conferences whose programs included female speakers, and this also became the policy of the National Institutes of Health (7). Moreover, in rheumatology there have been some advances in recent decades. The ACR has shown significant improvements in terms of women’s representation at its governing levels and standing committees, which has been achieved by an active program to recruit women to these positions. Indeed, both the president elect and vice president of the ACR for 2004 are women, and there is a high percentage of committee chairs who are women. In conclusion, the gender inequity that has been observed at the past EULAR and ACR meetings does not appear to be mainly a reflection of selection biases that might depend on a male predominance among the members of the scientific committees; rather, it reflects the situation in the higher academic positions in medicine in general, as well as in rheumatology, in most countries in Europe and North America. To change the situation, the creation of a truly equal environment, in which individuals with family responsibilities are not disadvantaged, is warranted. Factors such as availability of extended family help and inexpensive child care may be important, but based on the Swedish experience, we can conclude that this is not the complete solution. We also must take into consideration that gender sensitivity WOMEN IN ACADEMIC RHEUMATOLOGY is an important first step in solving the problems of gender inequality. Even small details, such as the number of woman speakers in a conference or female representatives in scientific committees, can be important. We believe that our major rheumatology organizations, the ACR and EULAR, could have a major impact on this issue by lending support and serving as role models for work to be performed on a national level. Woman scientists should also be gender conscious, and networks of women have always been helpful. From the Turkish experience, in which there is an almost equal number of women and men among faculty members, we could learn that different forms of affirmative action policies have proven very important in promoting women. Finally, low participation of women in different branches of science, including medicine, poses problems not only for an egalitarian society, but also for the future of science. Faculty diversity will facilitate creativity in academic research and scientific discoveries, and thus the medical community will be able to respond to a wider array of needs and demands. Because academic rheumatology is a medical field that is rapidly expanding, our specialty needs to attract and retain those individuals with skills in science and leadership. 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