The 25 Women project: identifying barriers and reducing stigma
15 March, 2021
Psychiatry is a complicated field, built upon an extremely exclusive foundation. The founders of modern psychiatry were almost entirely affluent, western and male. Their views, hampered by the limited world view this gave them, created a legacy of harm that is still being undone today.
Modern psychiatric systems remain inflexible and resistant in far too many ways but the steps towards change are happening. It increasingly feels that our voices as women in psychiatry and the voices of the women we see are having a bigger impact. There is movement towards eliminating obstacles and this change is led largely by women. Active support and empowerment to affect change is more important than ever and this is why we are celebrating these twenty-five women.
It is becoming increasingly obvious that genuinely trauma-informed care is needed, and that the profession continues to fail patients, especially women, wherever this is not employed. Inequality is also visible in the research gap with care strategies largely being extrapolated from gender neutral research that does not adequality address the importance of sex and gender, eloquently described by one of our twenty-five women Professor Louise Howard, and is largely from a western point of view. An echo of the inherent flaws in the foundation of psychiatry, this continues to affect our understanding of how illness presents, how we should treat it and how we can access it. These problems for women are likely to continue for as long as women are underrepresented in academia and diversity in our workforce remains inadequate.
As the trainee member of the 25 Women steering group one area where I see particularly visible barriers to developing diverse leadership is during training, a problem that is visited again and again in the narratives of our twenty-five women. An increasing imbalance develops during career progression, and men are still strongly over-represented in leadership positions within psychiatry. Somewhere along the way women are losing their path to advanced positions.
Why this happens is complicated and not well understood. Some of the more obvious reasons are where training remains rigid - particularly with regards to less than full time training or when returning to work from extended absences which largely affects female trainees. Issues encountered by LTFT trainees, such as with training needs, pay and rotas, often have very limited answers and questions about this are met with the bland resistance of ignorance: ‘we don’t know how to resolve that’. There can also be hostility towards women, LTFT trainees can be blamed for ‘choosing to be pregnant’ and producing these issues of inequality.
Returning to work after a period of absence is still hard and support is often poor with little to no account for how complex the reasons for this can be – development that has been made in this area has been led and championed by women who have found themselves in this situation and are having to carve it out for themselves, including women that we are highlighting today.
It is more apparent that international medical graduates are greatly disadvantaged in the training programme. Again, a burden all too common in our narratives.
There is also a stigma against paths that are alternative to achieving consultant-hood where leadership can still be strong, and a lot of valuable and dedicated work is done as many of our narratives are testament to.
We also see notable absences of women in specific fields. We see far fewer female consultants then male in general adult and academia, for example, whilst the opposite is true in CAMHS and perinatal psychiatry. Why is this? Are women gravitating towards the areas they are most interested in, or are they guided and pushed in that direction - discouraged from following certain paths, and led down others?
Hard work cannot overcome these obstacles when they are systemic issues especially where there is a poor understanding – they are draining and, worse still, they ask us to become implicit in their survival. Training in medicine involves accepting a certain level of engagement with a system that is biased against women, and it is easy for us to become blind to its faults. We can judge other women and envy can play a complicated role in our professional lives. I strongly believe that this is largely a reaction to, and a joining with, a patriarchal system that has been built to work against us.
Medical training is built with this embedded into it – with constant competition, performing in front of one another, programs to support us seeming punitive, and dropping everything to move to the next city and the next hospital. Challenges which can only be made so much worse with the experiences that we have if we differ from the demographics the system has been built by. If we are women, or people of colour, or have a disability, or our culture and identity is not reflected in the system or the people we have around us.
Part of the remedy to this is to find and celebrate women. To develop nurturing relationships and build space for each other and our different paths. Throughout my career I have met many inspiring women (professionals and those with lived experience) who have been determined to create a more understanding system that is able to learn and change both for the benefit of the people we see but also our colleagues.
A great deal of the narratives that we have received urge for unity and a sisterhood among women and many are doing wonderful work to support others. What many of our women have talked about is the strength of finding a tribe of who will support you, hear your experiences and celebrate you for who you are. The narratives today compel us to foster self-compassion and self-belief, explore the challenges of being an international medical graduate, being a physician mother with a child with complex needs, working beyond the conventional, finding yourself as the only woman in the room and not accepting ‘no’ as an answer.