25 Women; Celebrating Women in Psychiatry

Dr Beena Rajkumar hosts Dr Jo Talbot Bowen, Dr Ruth Reed, Dr Philippa Greenfield and Dr Julia Barber on the 25th anniversary of the Women and Mental Health Special Interest Group.

These incredible women discuss the progress made for and by women in psychiatry and the challenges that many have overcome. Read the stories of 25 amazing women on the 25 Women project page.

Transcript

Beena: Good morning, everyone and welcome to our podcast. This is the 25th anniversary of the Women's Mental Health Special Interest Group. The aims of the Women's Mental Health Special Interest Group are twofold. One is to promote mental health services for women and their families and the second is to enable women psychiatrists to achieve their potential, to have a voice, and to have fulfilling careers.

If you think about it, these two aspects are like two sides of the same coin. We know that when women psychiatrists have a voice and when they are in positions where they can make a difference and they are supported, this then enables them to make changes within the services to provide best care for their patients.

We are all women psychiatrists, and we want to reflect on the generic aspects of our careers as women in psychiatry, and our work with our patients, and also our own personal reflections. Let's do introductions. I'm Beena. I'm a consultant psychiatrist and psychotherapist working in Lincolnshire partnership foundation NHS Trust. I'm also one of the co-chairs of the Women's SIG.

Ruth: Hi, I'm Ruth Reed. I'm the co-chair of the special interest group. I'm a consultant Child and Adolescent psychiatrist and I work part-time across two teams. Jo.

Jo: Hi there. My name is Jo, Jo Bowen. I run the extra stress clinic. I'm a psychiatrist and I'm in this group. It's a wonderful group to be in. I have a special interest in stress in doctors and women doctors, and I have a special interest in treating trauma, psychological trauma, and anxiety. Lovely to be here.

Philippa: Yes, I'm Philippa Greenfields. I'm a consultant general adult psychiatrist working in Camden and Islington NHS Trust, and I'm the finance officer of the Women Mental Health Special Interest Group.

Julia: Hello, I'm Julia Barbara. I'm an East Essex registrar in general adult psychiatry currently working in Nottinghamshire.

Beena: If we start with the careers of women in psychiatry, we always start with the past history because it helps to understand the context and it's really important not to dismiss the past, to sweep it under the carpet. It's important for us to remember the past. Historically, we've had enormous challenges as women gained an entry into psychiatry and subsequently found a place in psychiatry. It's important not to forget this, Dr Kate Lovett, the Dean of the Royal College of Psychiatrists has outlined these challenges and difficulties that women in psychiatry had very eloquently in her brilliant talk, Where Were All The Women.

In 1871, the Honorable Henry Maudsley stated in his article Sex In The Mind and Education that the education, the Higher Education of women, would be detrimental to their own health and if they pursued education, it would impair their reproductive functions, cause loss of menstruation, infertility, underdeveloped breast, and an inability to breastfeed.

He was a man of his times. He was, however, also the president of the Medical Psychological Association, which was a forerunner for the Royal College of Psychiatrists. Women have historically had very little support and encouragement in taking up careers in psychiatry. Dr Eimer Bowman, who's one of our 25 women heroes, sent me an article that she wrote for the Irish Times in 1981. She mentioned an anecdote in which apparently at St. Mary's Hospital in London, in 1916, a major decision was taken to admit women doctors into training, and he replaced the written exams with an interview with himself, in which excellence at games was a prerequisite for entry.

By 1924, the admission of women were completely stopped. If you look at the history of our own Women's Special Interest Group, our founder, Anne Cremona, after the birth of a child, was refused permission to job share the consultant posts that she previously carried out for 10 years despite the intervention of the BMA and her identifying a number of psychiatrists colleagues who were interested in job sharing with her.

The wisdom of the day was apparently that no woman doctor could carry out the responsibility of an adult consultant psychiatrist putting in the long hours required whilst also caring for a large family. Comment such as part-time work means part-time commitment, we're also apparently very frequently made. At that time, flexible working was already a new concept. Only a few small numbers of part-time consultant posts were available in specialties such as Child and Adolescent Mental Health. Dr Cremona decided that the only solution was to resign her full-time post and retrain completely as a child psychiatrist.

This situation was brought to the attention of our first female president of the Royal College of Psychiatrists, Dame Fiona Caldicott, who encouraged her to continue her career and her chosen specialty and to set up a special interest group within the College for Women Psychiatrists. This led to the formation of the Women's Mental Health Special Interest Group in 1996.

If we come to the present in 2021, it is tempting to look at the visibility of women and psychiatry and think, yes, we have made it, but we just have to look at the data, the gender pay gap, career progression of women, allocations of Clinical Excellence Award, and know that it's still not a level playing field at all, we still have a long way to go to have gender equality.

If we look at the mental health of women with a pandemic, we know that women have experienced an increase in domestic violence. We know that women who experienced domestic violence have an increased risk, a three-fold increased risk of developing serious mental illness, we know that we have a long way to go with establishing trauma-informed services across the country. We still have a long way to go with making our services responsive to women's mental health needs.

The journey of women and psychiatry and the work that we do has, however, not just been one of struggles, but we've had tremendous success and made lots of progress and we've come a long way and we've overcome lots of obstacles. On our 25th anniversary, we really want to celebrate the accomplishments of women in psychiatry, both past, and present. People like Dr Helen Boyle, who became the first president of the medical Psychological Association, in 1939. Oh my, she was such an exceptional woman who apparently had triple qualifications as a surgeon, as a physician, and as a psychiatrist.

She was a woman far ahead of times, and she spoke about concepts such as early intervention, peer support workers, rehabilitation in psychiatry, as early as 1905. We sadly recently lost our first woman president, Dame Fiona Caldicott. She was our first woman president who truly broke the glass ceiling, and who made a tremendous contribution to psychiatry.

Apparently, six weeks prior to her becoming the Dean of the Royal College of Psychiatrists, she lost her son Richard who was age 19 in a car crash. However, she decided to use her pain to propel her into making enormous contributions in psychiatry. We have gone on to have other amazing women presidents. Professor Sheila Hollins, Professor Dames Sue Bailey, Professor Wendy Burn, we have had three women Deans and several other women leaders who've been trailblazers in psychiatry.

This includes past chairs of the Women's Mental Health Special Interest Group, Professor Mary Robertson, Dr Fiona Mason, Dr Nicola Byrne. Currently, 45% of psychiatrists are women. Women from different backgrounds, different grades, different subspecialties, who are quietly making enormous contributions in psychiatry.

If you look at the Women's Mental Health SIG, we have 4,000 members, and we have an excellent engaged committed executive team. We have 17 members on our executive team from different grades and seven of them are trainees. Ruth and I became co-chairs in November 2018. We met for the first time on the 21st of November 2018. In 2001, Prescott Street, our College building and when we spoke about what we'd like to accomplish, it was synchronicity because what was first on our agenda was our shared dream to celebrate frontline women, psychiatrists from different backgrounds.

This has given birth to our Women 25 Project. This project has been a dream come true for both of us. On a very personal note, this work has personal meaning for me, given my own matriarchal upbringing and my own very close attachment to my mother who was a feminist. I must say that working on the project with Women 25 group, the working group, Ruth, Philippa, Jo, Julia, Ilaria, like-minded women has been so much fun. We've had a real sense of solidarity and sisterhood. I will now pass it on to Ruth to unveil the Women 25 project.

Ruth: Beena and I have a lot of shared interests but the areas that we particularly started talking about when we first met were around women's leadership and how women are often quiet leaders within the teams, not necessarily putting themselves forward for recognition. We were also interested in complex trauma and in thinking about how people succeed in difficult circumstances. I guess personally, when I first started thinking about all this was during my second pregnancy, I'd been very unwell in both of my pregnancies throughout them both and lost a very large portion of time when I might've been doing professional development goals.

I guess that's set my career in a somewhat different direction from where it might've gone very unexpectedly. I was actually applying for one of the RCPsych Awards, but at that point, I couldn't even sit up. I was so unwell and it was very difficult to fill the form in because I had very severe pregnancy sickness. I thought if I don't fill it in now, when will be the next time that I'm going to be able to put myself forward for one of these awards. I'm going to be on maternity leave. After that, I anticipate that I'll come back working part-time. It would probably realistically be several years before I would again be able to put myself forward for a RCPsych Award.

That got me really interested in thinking about the level of disadvantage that we can experience when we take career breaks or when we experience illness or start working part-time, it can become quite hard to showcase what we're achieving. That was my personal angle on how I got interested in how we measure success and achievement, whether we're really measuring the right things.

I also got very interested in thinking about what achievement really means. I think it's not always that difficult to have a lot of things accumulating on your CV if your life's going very smoothly. If your life isn't going smoothly, it's often an enormous success just to turn up at work and keep coming in every day through that. I don't think we give anything like enough respect or recognition to women as they have major challenges in their personal lives or health or disability.

Beena and I started talking about it and really wanted to do something interesting to look at everything that was going on behind the scenes. Fortunately, we found several other women who are all part of this podcast apart from Ilaria, who can't join us today, whose energy has really taken this project forwards.

For the project, we really wanted to look at women who didn't previously have visibility or a national platform. We looked out for women who were very respected within the local areas and teams, but who might not be known beyond that. Going back to the idea of quiet leadership, we believe that a lot of women are making enormous contributions in terms of teaching, support for trainees, and support for their teams, and clinical direct care of patients, which don't really get effectively measured and valued through the systems we use such as CEAs. We've particularly tried to find those women and represent them through this project.

We've also included some women who are a bit better known, but two felt ready to share some of the backstory to their achievements, including illness and disability at times, mental health difficulties. We wanted to make sure there was space for their stories to be heard too. We've developed various multimedia outcomes to the project. There's the short film, which includes about half of our women. We also have in-depth resources. Each woman has put forward a really detailed narrative of their career. There are 25 of those along each introduced by a blog.

We were really excited to be able to have a celebrator project about women's achievement it's for our 25th anniversary, but we've tried to make sure that our presentations of women's careers are realistic. They aren't CV-based explorations which are just the list of achievements. We really wanted to look at the how and why of success so that it would be instructive for other women and people who are coming up behind ourselves.

We've tried to avoid people honing in on lists of achievements to really look in-depth that's why they made decisions that they did and what has helped them along the way. At this point, it would be great to hand over to you Philippa to talk a little bit more about some of the relevant factors for women's psychiatry.

Philippa: Thanks, Ruth. I wanted to start by talking, just expanding a little bit on the idea that both you and Beena spoken about, why it's so essential that we have women in psychiatry workforce, and more importantly, why we have diversity in our workforce because we absolutely need that diverse leadership and that perspective, if we're going to be providing services for the diverse population that we serve. Arguably, we're really doing a disservice to those, if we don't address that and don't have people representing different perspectives in our leadership and as doctors.

I wanted to talk a little bit, so before we maybe think a little bit more about what our workforce currently looks like, I wanted to think about some of the work that I do and my interest around domestic abuse and domestic violence, which I mean really does. I think we could all agree still is a work that is driven within medicine and more widely by women and from the women's movements. I wanted to talk a little bit about my work in that area and what's really driven that. I primarily work in community psychosis services in London.

I suppose that work for me or what's led me to that work is really my interest in inequality. We can think back about our careers, about why all of our interests is started, but I suppose my first real taste of some of these issues was slipped before working as a doctor as quite a really, in my younger days, working in the modeling industry. It was at this point that I first really became aware or confronted by what I now know to be a power imbalance, something I probably didn't recognise or understand at the time. It was something that's really stayed with me and is very much interested in me in my later work about what this was about.

As a medical student, very early on in my medical student training, I then chose to when to take a special study module with Professor Gene Feder, who now is a consultant working as a professor working in Bristol university, but at the time was working clinically as a GP in Hackney with a special interest in domestic abuse. It was through my work with him that I got the opportunity to work with women who were living in refuges in the time in Hackney and around Islington, and also to sit on the MARAC, the community MARAC at the time.

This all came back to me about seven years ago, because at the time, I was working, as I said, with an interest in psychosis, in an early intervention service, and about seven years ago, I was tasked with a particular project because the early intervention service that I was working in Islington was working with people who presented after the age of 35 with psychosis.

People who presented it to later stage in life. It was the first time that I that something really started to make sense to me. What was very different about these, I would say largely women, because we know that women do present more frequently in later life with psychosis. What was very different to the conversations I was having with my younger patients is that the women would be much more able to tell me what had happened to them and maybe the people around them or themselves to say things were going well, I had to life, I had children, I was working and then something happened.

Whether it was described in these terms or not by the women, what I was seeing time after time was that these women were describing to me what had happened or part of what had happened to them was really around experiences of domestic violence and sexual abuse. I was really seeing that time after time.

What I would often find from talking to them more often was actually this wasn't the first time or that they might be having presented to mental health services for the first time with new experiences as time, often those experiences have been present in some form in their early life as well. I suppose what went on to interest me is that what women were bringing, what women were coming to services for derogatory voices, ideas of being followed. Well, these felt really quite understandable when you were thinking about the context of these women's experiences and what had happened to them.

It really brought a very different thinking and understanding to my work. I suppose at this time,c alongside wanting to present this and some of the findings I was preparing for research, actually, what felt urgent to me as a clinician was that I really needed to upskill in this work. I needed to find out practically much more about domestic abuse and how we respond in a very practical sense to that, which I continued to take every opportunity to do but to also to improve my understandings of trauma and hear complex trauma.

I suppose going on from that, how do we bring this understanding and this work to probably the most disadvantaged people that we see in our services? The people with serious mental illness, severe mental illness that I work with, who may not be able to, who may be real barriers to communication and advocacy for themselves, which is what got me then further interested in this idea of trauma-informed approaches.

I can honestly say that the work that I have done around domestic abuse and domestic violence, and more recently trauma-informed approaches, has really, I feel enriched my clinical practice more than anything else I've ever done. I think never more can be said, just we've referred to the join, the current pandemic when we have seen such a huge increase in serious harms as a result of domestic violence and abuse and something that we've absolutely urgently had to attend to.

I just wanted to give some context to that, but I'd be really interested because Ruth, you work as a child and adolescent psychiatrists with particularly in an area for the young people who've experienced sexual harm, as I understand it, and Beena, as a psychotherapist and working in a women's only inpatient service. I just wonder if there's anything that you wanted to mention thinking about some of the things I brought up?

Beena: I think so, and I work only with women. I didn't plan to do that, but that's how it's evolved. I absolutely find my work very meaningful, both as an inpatient psychiatrist and as a psychotherapist in the community, working with women who've experienced complex trauma. I think I go on about history because I think history is so important. I think if taking a trauma-informed approach is absolutely central to the work that we have to do, and we really need to drive this forward because I feel if we just use diagnostic criteria, it blames people, it says, what's wrong with you? You have a problem, there's something not quite wrong with you.

We need to change that narrative to saying, "What went wrong with you, what happened to you that was wrong?" I think trauma-informed care helps us do that. I think that's absolutely got to be central and it's got to be the soul of the work that we do with women.

Philippa: Ruth, I was interested because I think what I see with my older patients, to my adult patients, is they say sometimes is that people can self-report or tell me more about what's happened to them. I wonder how you find that in the service working with younger people and how you may have these conversations or what you might find about having these conversations with younger women?

Ruth: Well, I work in two services, one, as you mentioned, as a specialist service for young people and families after sexual harm and the other service, is all conditions in CAMHS but what is quite incredible is the degree to which the families in both services have experienced domestic abuse and multiple forms of adversity. One of the things that is so evident is how adversity and trauma really snowball and how much one event leads to other forms of adversity and the cumulative impact on the whole family from all sorts of different angles is really enormous.

Philippa: Doesn't it feel fascinating then that we don't embed this more in our work or in our early training, because I think we're all familiar with the ACE studies that were done and exactly as you described Ruth, we find just from talking to our patients that these themes that we know these themes are present of adversity and trauma but it absolutely isn't ingrained in our practice yet, or certain in the way that we ask people about their experiences. I just think it's fascinating. We're all here saying that this is absolutely the core of all work, but yet we don't really feel we're in a workplace that fully recognises or thinks about that in everything that we do.

Ruth: I agree. In the past couple of years, I've been teaching foundation doctors on the impact of traumatic events and have also recently introduced a lecture for medical students. There are similar developments going on across different medical schools and training programs. That's exciting times, but in a sense, it's hard to imagine that this hasn't happened earlier.

Philippa: It does come back to this question, doesn't it? I think that we do seal, as I said, this work in particular still does seem to be driven largely. I certainly know when I get to training events and we've all spoken about this before, but actually, when these topics are spoken about, they're largely attended by women, and I think this work is something that has really been driven by women. There are absolutely exceptions to that.

It does come back to the point about the importance of women and women leaders. We're still in a real position, aren't we, that we don't have women represented at similar levels in the NHS, in consultant roles. We still know that two in three consultant roles across medicines, not particular to psychiatry, is taken up by men. We also noticed in academic medicine that women are really underrepresented at the very senior academic levels.

I'm fascinated as to what, to why, and it is a problem. We know we have women entering medical school now at higher rates than men. I think 60% of medical students are women now, and that, by the time we get to training, even so, doctors in training, two-thirds of doctors in training are women but I've seen it first hand. Again, I've been a consultant now for six years, but even in my training, which was not that long ago, I would still recognise that it was very strange as I progressed in my trainings, the women, the fantastic women around me would disappear, particularly in general adult psychiatry.

I would think, well, what's this about where are they going? Why are they choosing other things why they're not continuing their career? Actually, I can say the people that I started my psychiatry training with, the other women, I think the only one that continued through to the general adult psychiatry. I think that it was probably only at that point again, that I noticed at the point of then becoming a consultant. I think the barriers that I faced at that point were, as we say, the consultants that largely, that are employing us and that are playing our services are largely men.

Also going through my own experiences as a consultant of pregnancy and maternity leave gave me a better understanding, I feel as to why that might be the case. I suppose we've had positive movements. Even since I've been a trainee, we've had the 'me too' movement, which has had an impact on everybody.

We've had the mandatory and gender pay gap reporting since 2018, although it hasn't been reported and put on hold during the pandemic. Unfortunately, in medicine shows that things, in the two years of reporting, shows that the gender pay gap increase from 15 to 17%, men being paid 17% more than women during that time but we do have those things in place. I'm very interested. We've got a real breadth of age on the panel and I'm interested in people's experiences. Particularly Julia as the youngest men member on the panel today and who is still a trainee about to compete training and whether Julia feels things have changed for trainees.

Julia: I think there is change but I think there is still a long way to go with this system, particularly around training as that is my main experience so far. The system is still so inflexible and so resistant in many ways, but what we are seeing, what you say with these movements that we're seeing is a more empowerment of women and a feeling that our voices are mattering more.

The changes that we're seeing, this is important because the changes are largely from women and being led by women that benefit us. That's just so important. Like you say, I'm coming to a stage of my career where things are going to be changing, but also as currently, I'm pregnant, again, it's another thing I'm thinking, wow. Things are going to be changing in amazing ways, but also is this going to mean that there are barriers that are going to be increasingly stacked against me? Like you say, it just seems that there is somewhere along the way, particularly in training, where we seem to lose women.

This has been a common theme in a lot of the narratives that we've had from our 25 women as well as the struggles through the journey to get where we are. Some of the most visible reasons I feel do still remain with this issue about rigidity and how the training system and career system responds to the way we enter our careers. The ones that you hear time and time again, is the problem with less than full-time working, which is still predominantly women, because the main reason people are less than full-time training at the moment is caring responsibility, which normally comes down to women.

I sat in these meetings where I've been more of a backseat passenger so far, hearing just, male leaders of the training program, blaming women for blocking up training placements, and also how frustrating it is to fit in these women trainees, who are less than full time, who've gone off to get pregnant.

Also what happens is, in these same meetings, these trainees are bringing up issues that they have, issues that come up time and time again, like rotors and pay and how this is sorted, but there's never an answer. It seems to be what you're faced with. It's always, well, we don't know how to fit that and we'll have to look, but what's so obviously frustrating is it just keeps happening that way.

What I am seeing around me, thankfully, is people are trying to challenge this themselves. It's unfortunately happened to come down to the people who've had to carve their way through. Another issue being, as Ruth was talking about, absences from work and returning to work. There's no real respect to how complex the reasons why somebody has been absent work can be.

Again, women are having to sort this out ourselves and advise the career structures around us ourselves, and that's, in ways that is a bit depressing that we're having to ourselves, but it's also hopeful for me anyway, that I'm seeing that visible change.

The other reflection I have is that, when it is systemic issues like this, it's not that hard work can overcome these obstacles, it's this lack of understanding and also a bland unwillingness to understand as well is what it feels like, which is a resistance to the change. That could just be so draining. A lot of the experiences in training can be draining, which leads me to think a bit more about some of my own personal reflections about my own personal journey, in psychiatry and through my training process, because I've always been somebody who's really been wanting to work with women. It's a huge passion of mine.

I come from a very matriarchal family actually, which is probably where it comes from, and also a family where there has been struggles, particularly for the women in the family with mental illness. It just really compels me towards this goal. What I really was surprised to find along my journey was this part of ourselves as women that joins in with this system that is stacked against us and really what came down for me was this issue with envy.

This is really important issue in feminism and certainly, I have experienced where women can be hostile towards one another and women can put up blockades for each other. What was really important for me was to realise where this was coming from myself and how inhibitory that was and how stuck I was getting and not progressing in the way I'd wanted to, because of just how much that was building up.

That doesn't necessarily come from inside a person, it comes from a reaction of a person towards the system around them, is my real reflection the. Recognising this poisonous feeling and the guilt and shame was part of what became healing because where it becomes very relevant to training is that I feel training in medicine, it does come hand in hand with a lot of guilt and shame and humiliation, which is built into the process.

Not that there isn't also joy and brilliance and exhilaration in training, but there's also this part where we just expect the doctors to just get on with it and perform in front of each other and compete against each other and just give up everything and move to another city and to sacrifice. It's something that I worry that it becomes a really ingrained and internalised part of ourselves. I was just wondering if anybody else in the panel had thoughts about that as well or any other personal reflections about that?

Philippa: Just one thing to say. What you're describing Julia is the pathways and I think this has been my experience still the pathways for training just still aren't designed for women. It doesn't feel they are. The other thing is, in terms of why women might behave in a certain way or might behave, one thing that doesn't help or that will help increasingly is having more women in senior roles and more women as mentors because I know for me that one of the most important things for me and actually why I probably have been able to continue in my career is finding women who have been more senior to me, who have understood these issues and have really guided me through.

That is something again, that we have lacked. We've lacked women to create the system, but also the women to support us to say there is a different way of doing things. We can do things in a different way. It's okay to bring different characteristics and a different perspective to have children, all of these things, and still be a doctor. For me, it's been a huge challenge through my career to say, it's okay to be you, you don't have to find a way to fit and do things in the way that other people do. That's my take on maybe what you're saying, but it'd be interesting to hear what others have to say about that as well.

Beena: Julia, I really, really loved your reflection. I really loved your reflection when you spoke about the internal experience of envy, because I think as women, we are so interconnected, we are quite social-centric. We are made to be, we're not very armored and actually, we are not very effective when we are armored. We're most effective when we have a semi-porous membrane around us, where we are able to be receptive to the people around us, where we are able to be receptive to that sense of connection.

When that works well, the light side of that is, when I say light, I mean the brighter side of that, is that we are more impacted, we are more caring, we're able to connect and we are able to be more responsive, but the shadow side of that social centricity, it is that we tend to compare and we do compare ourselves with other women and sometimes, that can lead to a sense of envy, as you said.

The envy, and also the sense of self-denigration, feeling that we are not as good enough and looking at the choices other women have made and looking at ourselves as less than. A part of our inner journey is to be very, very aware of that darker shadow side because it will exist and it's a lifelong journey of trying to understand it and trying to feel that builds that sense of, "I'm enough, I'm okay, I'm enough. These are my life choices, this is what I want to do, this is my journey. Let me run my race, let me find my track, let me do what I have to do."

Jo: I thought that was a brilliant reflection, both Julia, Beena, in fact, everyone. As someone who hears women doctors' stories in a clinic, I reflect that actually, it's the stories. We've been coming up with this our own personal stories today, which are deeply moving. I think that this whole business about what is hidden is vital to unveil. In the clinic that I've been running over the last six years, seeing women doctors, there have been trends that I've picked up. This is a period stretching back from before the junior doctors' strike, which was deeply stressful and conflictual for doctors and indeed for everyone.

Then very sadly we've had quite a number of doctors take their own lives. Actually, we know that female doctors have a higher rate of suicide compared to the average rate for women. Wee've also now obviously gone through, we're still in the COVID pandemic. During this time also we've seen wellness programs for doctors being created and being resourced, but clearly, we have a problem with what is hidden, what value systems we are allowing in terms of care ethics in society now.

The sorts of trends of the sorts of things that people, that particularly women bring to my clinic, I think are very important to, as I say to unveil, there is this business of the so-called imposter phenomenon. Some people call it a syndrome, but I think it's more phenomenon and what's coming up there, and this is actually something which a lot of senior women doctors come with. Perhaps somewhat surprisingly is that in these relatively high functioning people, there is this report that they don't feel they fit in, that they feel that they have this terrible secret that they cannot ever prove themselves to be good enough.

In more junior female doctors, it's perhaps not necessarily seen as an imposter phenomenon, but it's seen as a deep anxiety that as many of the stories we've heard of today show that actually, it doesn't feel a good landscape for women to be in at the moment in medicine and indeed in society. There is this business of stigma.

There is a need for, and for example, the doctor support network have put out an excellent campaign called "and me", which is trying to show that doctors are humans who are suffering. I think for women in particular, the suffering is very great now, and my hope is that the COVID pandemic will further unveil the sorts of squeezed care problems that women are experiencing. Now, if it's not for themselves, it's as parents for their children, it's for children for their parents and all of this is going on in a landscape where women feel actually very taken for granted.

I think that whole landscape needs to change and I think that the value of our project, 25 Women is that the stories of 25 women psychiatrists are being shown and are being celebrated for what they are. What we do know is that there's room for a huge amount, I think more listening to women's voices in terms of trauma with a little T or a big T, the whole business about simple trauma for every person, every woman. Right from actually before birth, where we know that adversity can happen well before birth to really old age, I'm the oldest person on the panel. I think that what we're missing is a whole lifetime of understanding half of the population much, much better than we do.

Hormonal shifts are massive during that time for people. Indeed, the whole landscape, the whole complexity, the whole business of how we do complaints, of conflict in society, and what we're missing, not what we're seeing. That's where I want. I'm passionate about trying to change that landscape. In thinking about this whole landscape of disempowerment for women, and women not feeling like they fit in, feeling like this is a sort of hidden, terrible secret, it's difficult to unveil for them, trying to find a way through.

Of course, there are lots of individual issues, but in terms of themes, we do know that gender isn't the only issue to consider. there are certainly other attributes, other work experiences, which are very important to consider as well in terms of almost a double whammy of disempowerment for women. I think Philippa, you've got some, some reflections on that too, haven't you?

Philippa: I agree, Jo. I think we spoken a lot, obviously with the focus of this podcast about thinking about gender, thinking about women, but actually, what we've maybe focused less on so far is thinking about different identities. Thinking about when we talk about the gender pay gap, we've spoken about how that impacts women, but actually what we haven't spoken about is that there is still no mandatory reporting of the ethnicity pay gap, but what we do know for women doctors, that Black women doctors bear the worst in terms of the pay gap for doctors compared to everybody else.

Also, when we're thinking about issues of women in society and the access of our services, we were talking earlier about domestic abuse. Again, we know that, and as was highlighted actually during the pandemic in a fantastic report that actually, the effects of domestic abuse have been felt much more during the pandemic and prior to that by Black women. We really need to be thinking here, we've been talking particularly about gender, but we need to think about issues for people, for women, who are women, but there are also barriers for.

Beena: If you think about the experiences of women of colour, we are talking about a very heterogeneous group of people and we also talk about very different life experiences. First-generation immigrant women versus second-generation immigrant women. First-generation immigrant women are those like myself who come to this country after the age of 11 and second-generation immigrants are those who were born and raised here. There are different sets of psychological and mental health problems are very, very different.

The first-generation immigrant women struggle with issues like transition, loss. You're losing your own culture and you have to fit into your host culture. Issues with trying to assimilate into a different culture. Whereas the second-generation women, they struggle with issues of identity, feeling sometimes like an outsider and grew up growing up in a culture, which is very different and thinking about what is better and what is inferior and what does superior and so on. The health problems are very different.

When we talk about the experience of doctors, women of colour have, especially if you're thinking about first-generation immigrants, we know that they are less successful in exams. If the results, the MRCpsych exams, especially with the CASK, the clinical assessment exams, they're less successful and basically, people of colour come from socio-centric cultures. We are very taught to worry about what other people think about us. The sense of taking a failure on an exam, it's not just an exam, it's a life event.

The sense of shame is very, very profound. I've seen trainees, I've seen colleagues who just completely, their sense of self-esteem, their confidence identity gets crushed after failing in exams and the lose the momentum and they don't make a career progression. I suppose that's the issues, there's such a sense of shame, external shame. I think as women, that's what we need to help them. As women leaders, that's what we want to help them with to understand and to say and I think the Women 25 project is trying to do that.

Philippa: Yes. I suppose, because it really does. I think one of the things about the project that really does show that diversity, but I think with what you were saying, Beena, it really comes back to that idea about how important it is that we have diversity in our leadership so that we can support women from different backgrounds, with different experiences through their training and to go on a success in their careers, but also so that we're really able to provide services that really do address and think about the issues for women across the board.

Beena: Absolutely Philippa, but it's also redefining success. Success is not just not becoming a consultant, a medic co-director, and so on. It's about everybody's journey is different and if someone's had a difficult journey, then it's having that self-compassion to say, "okay, given my experiences, given my journey, I'm happy with what I've accomplished. I'm not going to compare myself. I have that self-compassion. I'm going to nurture myself and find meaning with what I do," and that to success. I suppose the 25 Project is to foster women who make those choices and celebrate those women and foster a sense of self-compassion.

I think that brings us to a beautiful ending. I just wish we, I mean, I think we could spend a whole day talking about these issues. At this time, when we are celebrating our 25th anniversary, I think we look back with a sense of, we are not where we were, but it also feels we are not where we should be and it feels that we are on a journey and hopefully a journey of as Julia said, a very authentic journey where we are trying to find both within our personal lives and our workspace, things that are meaningful to us, so meaningful to us in a very, very personal way. With that, we end this podcast. Thank you every everyone. Thank you so much.