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Women in academic rheumatology.

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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. Given
these circumstances, and with rheumatology being a
specialty that attracts women, we now have an excellent
opportunity to actively promote woman scientists in
rheumatology and thereby give rheumatology a more
competitive and diverse edge in academic medicine.
ACKNOWLEDGMENTS
We are very grateful to Drs. Leslie Crofford, Barbro
Dahlbom Hall, and Lars Klareskog for critical review of the
manuscript, and to Ms Åsa Lundberg, Amy Miller, Emma
Ravald, Åsa Ytterberg, and Drs. Mary-Carmen Amigo, João
Carlos Brenol, Barry Bresnihan, Anca Catrina, Bente
Danneskiold-Samsoe, Maxime Dougados, Renate Gay, Kerstin Hagenfeldt, Yoko Hashimoto, Marija Hietarinta, Tore
Kvien, Kayo Masuko-Hongo, Deborah Symmons, Jorge
Sanchez-Guerrero, Jiri Vencovsky, Thea Vliet Vlieland,
Marius Wick, and Angela Zinck for their invaluable help in
providing information regarding the status of women in rheumatology and medicine in different countries.
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