Over the past 50 years, the representation of women in the rheumatology workforce has increased significantly. Despite this demographic shift, gender inequity and underrepresentation of women in senior rheumatology positions persist. In this article, we consider the state of gender equity in rheumatology, highlighting both the advances and the ongoing challenges. We explore the systemic factors and implicit biases that continue to perpetuate inequity while assessing strategies from the broader medical literature aimed at promoting equality of outcomes for all medical professionals, regardless of gender. Achieving true gender equity in rheumatology necessitates a concerted effort to address implicit biases and foster an inclusive environment that promotes equal opportunities for all.
Female representation in medicine has improved, propelled by antidiscrimination legislation and the implementation of institutional policies aimed at addressing gender inequity.1-4 Rheumatology exemplifies the increasingly desegregated medical workplace, with a growing presence of female professionals in what has traditionally been a male-dominated field. Yet despite increasing representation, true gender equity has not yet been achieved.
Herein, we explore the construct of gender and summarize the data available to assess the extent of the gender gap in rheumatology. We consider factors that impede the career progression of women and highlight the need to move beyond surface-level metrics to understand the systemic factors and cognitive biases that perpetuate gender inequity.
The case for gender equality
Gender—as distinct from biological sex—is a social construct based on political and sociocultural norms. Gender identities and gender roles carry specific meaning that result in hierarchical relationships and an unequal distribution of power and entitlements.5 Gender identity and the persistence of gender stereotypes are informed by multiple domains, including work, economic status, education, access to leisure, health, and the sociopolitical environment. This multidimensional nature of gender contributes to uneven gains in the pursuit of equality, meaning progress in one domain does not necessarily translate to improvement in another.6 The “gender equality paradox” observed in Western societies illustrates this phenomenon: despite advances in sociopolitical and economic equality, deep-seated stereotypical beliefs about the fundamental differences between men and women have become more pronounced.6 Within the medical profession, despite decades of female achievement, both men and women still strongly associate men with career achievement and women with domestic responsibilities. Men continue to be associated with careers in surgery and women with general practice.7
Gender equality is achieved when individuals have the same value and are afforded the same individual rights, responsibilities, and opportunities, regardless of their gender.8 This does not mean that all individuals must be treated identically or receive the same resources. True equality acknowledges and respects individuals’ differences.8 Because people encounter diverse barriers and have different needs, gender equity is the process through which equality can be achieved. Gender equity ensures fair treatment by providing individuals with equal access to opportunities, protection from discrimination and harassment, and the resources they need to succeed.8 This may involve individualized treatment, tailored to specific circumstances, that is considered equivalent in terms of rights, benefits, obligations, and opportunities.8 Equity acknowledges that equal treatment is not always fair and seeks to address systemic disadvantages. As such, equity is the means through which genuine equality can be realized (Figure).
Equity leads to equality. Created in BioRender. Day, J. (2024); BioRender.com/d17d781.
Reliance on summary statistics to map trends in women’s status fails to adequately explain persistent patterns of gender inequity. Considering only the proportion of women within the profession does not capture gender biases that continue to exist in relation to hiring practices, promotion, and exposure to sexual harassment and violence.9 Quantifying gender representation alone may lead to an overestimation of women’s presence within the workplace. Importantly, the perception of women’s overrepresentation is associated with a greater unwillingness to support initiatives designed to promote workplace equality.9
Beyond generalities: Gender equity in rheumatology
There has been increasing interest in gender equity within rheumatology. The collective findings of this body of literature are concerning (Supplementary Index S1, available from the authors on request). Although there is relative gender parity between men and women in the clinical workforce, there is an ongoing discordance between gender representation in senior roles, particularly within academic rheumatology.10 Women are less likely to be full or associate professors and are underrepresented among presidents of rheumatology societies.10-12 They are less frequently recognized with prestigious career awards in rheumatology13 and remain underrepresented in senior authorship positions, particularly for basic science research, randomized controlled trials, industry-funded studies, and guideline development.14,15 The editorial and peer review system similarly lacks diversity, with underrepresentation of women at all decision levels.16 Fewer opportunities to progress and a lack of transparency in board appointments are considered key factors affecting women’s advancement to editorial board positions, more so than any concerns regarding work-life balance, child-caring responsibilities, financial constraints, poor mentoring, or limited career advancement skills.17 Women are underrepresented as moderators, invited speakers, workshop presenters, Meet the Professor speakers, and abstract presenters at international conferences.18 Geographic differences do exist, with certain conferences achieving more equal gender representation, potentially owing to a greater proportion of presentations from trainees or more egalitarian local culture norms.19,20
The increase of women in the clinical workforce means that in many countries, the gender identity of the rheumatology workforce more closely reflects the gender identity of the community at large.21 However, this has resulted in concern about the “feminization” of the rheumatology workforce, and led to a narrative of imminent “workforce crisis” owing to concerns that women work fewer hours than men.21 However, rather than performing “less work,” the ways in which women rheumatologists practice may merely be different. Data from Canada22 and China23 have shown the clinical workload to be equivalent between male and female rheumatologists, and German survey data indicate that both men and women rheumatologists work a greater-than-full-time load.24 However, women appear to see fewer patients and receive less remuneration despite similar overall work hours.21,24
Gender discrepancies within senior levels of rheumatology do not reflect differences in leadership aspirations, perceived self-efficacy in career advancement, or capability. No gender-based differences in career ambition are observed among early-career rheumatologists, and there is equal workforce involvement and funding success in the early-career period.25,26 However, equal career achievement is not sustained throughout a rheumatology career. Rheumatologists have proposed evolution of institutional norms, a higher acceptance of part-time work models, increased opportunities for skills-based training, higher visibility of female role models, availability of parental leave, and affordable childcare options at work as strategies to improve gender equity.25,27 Concerningly, women continue to experience workplace sexual harassment and violence far more commonly than men.24,25 No study has directly addressed possible solutions to this ongoing gendered harassment and violence.
Strategies to improve gender equity
There have been calls for medical institutions to consider and lead a challenge to the societal expectations of “appropriate” male and female gender roles.1,4 Initiatives such as the Athena Swan Charter have actively promoted and supported the establishment of institutional cultures of equity and inclusion (https://www.advance-he.ac.uk/equality-charters/athena-swan-charter). Proposals to address potential biases of hiring committees have included unconscious bias training and the implementation of “gender champions,” decision support tools to aid the application of selection criteria, and use of artificial intelligence to screen potential candidates.2,4 It is notable that in one academic hospital center, a deliberate departmental strategy of specific, structured mentoring and a commitment to transparent hiring and promotional opportunities was adopted; this resulted in an equitable promotion of both men and women and was widely accepted by staff of all genders.28
Workplace policies should challenge any stereotype that is underpinned by the false assumption that men inherently prefer to single-mindedly focus on career and leadership duties, with deferral of any personal or domestic duties.5 Both men and women prefer an egalitarian split of both earning and domestic duties when offered the choice.29 Development of gender-neutral parental leave policies as well as centralized parental leave payments such that they do not affect study budgets are strategies to improve access and acceptability of parental leave access for all employees.4,30
Gender equity initiatives frequently focus on empowering individual women, with a proliferation of programs designed to enhance women’s personal efficacy. Although these initiatives may have value, they are predicated on the assumption that if women were more confident, better time managers, more political, or if they made more appropriate life choices, then gender inequality would diminish.31 This implies that inequity can be solved by demanding women change, adapt, and work harder to fit into and succeed within an inequitable and persistently gendered system rather than addressing the underlying institutional and societal frameworks that distribute power and opportunity unevenly.
The European Alliance of Associations for Rheumatology (EULAR), as the organization representing health professionals, patients, and rheumatology societies in Europe, has convened a task force to gather empirical evidence of the unmet needs of women rheumatology health professionals in Europe.25,32 The National Institutes of Health (NIH) has identified key areas in which women applicants remain relatively underrepresented and has introduced pilot administrative supplement programs to support the transition of investigators to independent researchers, as well as the introduction of paid leave and flexibility policies supporting periods of parental leave.33 There are now rigorous reporting requirements in relation to instances of sexual harassment associated with any NIH-funded program.33 In 2023, the Australian National Health and Medical Research Council implemented a structured priority funding policy to ensure equal total funding for men and women, with a focused intervention to ensure women continue to be funded at later career stages, as the most significant gender gap exists within senior researchers.1
Strategies such as antidiscrimination legislation have made explicit biases unlawful in many places around the world and have resulted in significant gains toward gender equality. However, the momentum of advancement has decelerated in the face of challenging implicit gender biases. New understandings of gender discrimination, inequality, and equal opportunity are required to achieve gender equity.5 Rheumatology, like all fields, must take a proactive stance of self-examination and systematically collect pertinent data in order to formulate relevant and effective policies and strategies. The challenge remains for us to transform our culture of work devotion and its associated gender biases into a medical and academic workforce that values individuals beyond traditional dichotomous gender norms.
Footnotes
FUNDING
LR is supported by an RACP Arthritis Australian D.E.V. Starr Research Establishment Fellowship and a University of Melbourne Strategic Grant for Outstanding Women.
COMPETING INTERESTS
The authors declare no conflicts of interest relevant to this article.
- Copyright © 2025 by the Journal of Rheumatology