key: cord-0800316-ct3yqoqw
authors: Ayyala, Rama S.; Coley, Brian D.
title: Promoting gender equity and inclusion through allyship
date: 2022-03-22
journal: Pediatr Radiol
DOI: 10.1007/s00247-022-05345-3
sha: 34a9e16f8f160294d9880204763c460c1bdc8b34
doc_id: 800316
cord_uid: ct3yqoqw

nan

Professional advancement of women in pediatric radiology has lagged that of their male colleagues. The gap has been improving in recent years; however, a significant difference remains. This has been exacerbated by new issues that arose with the coronavirus disease 2019 (COVID- 19) pandemic. In order to continue making progress, concerted efforts to promote female academic advancement need to be prioritized. Mentorship and sponsorship have been extensively discussed as important factors in career advancement. However, an additional crucial component receiving less attention in the medical literature is allyship. The purpose of this manuscript is to discuss the importance of allyship in the career advancement of women and to highlight different examples and ways to practice allyship. Allyship is important for any under-represented group. The concepts presented in this paper are applicable in a variety of situations; however, they are introduced in the context of gender equity (see 1 ) .

Allyship has been defined as individuals providing "support for and practice of promoting rights, representation and inclusion by members of an advantaged group to advance the under-represented or marginalized" [1, 2] . This person is an advocateusually with privilege and power -who speaks positively on an individual's behalf and also defends and speaks out against discriminations and unconscious biases [3] . It is not a one-time opportunity but rather a lifelong process of gaining awareness, building relationships and trust with those in marginalized groups, and developing self-accountability for behaviors and actions. This should not be done out of guilt or with the expectation of receiving recognition, but rather it should be considered a responsibility as the right thing to do [4] .

Mentors are those who offer advice on career and work trajectories. They are trusted advisers who help during challenging decisions and transitions. These individuals can use prior knowledge and experiences to guide others [3, 5] . Sponsors are champions. They advocate for an individual, especially to those with decision power, and can potentially affect career trajectory. Sponsors use connections and assets to create opportunities for an individual. This can include gaining new skills, new positions, expanded networks and new career opportunities [3, 5] . Allies use their inherent power and privilege, such as being a part of a dominant or majority group, to advocate for those in marginalized groups. An ally can also be a mentor and sponsor, with the ability as an ally to positively portray an individual, dispel misconceptions and promote more awareness and recognition of those who might not get this otherwise. There is overlap among these roles, and all are crucial for career advancement.

Compelling data show that diversity in the workplace can have advantages. Discussions including people of diverse backgrounds have been shown to be more objective, with more effective data analysis, and to result in better received and executed decisions. Diverse teams work better together and are more productive [6, 7] . One aspect of diversity in the workplace is gender representation. Creating a gender balance in health care leadership and workplace teams can have numerous benefits, not just on the employees but on the overall workplace, including higher employee engagement and lower turnover rates [8] .

Approximately half of pediatric radiologists work in academically affiliated practices [9] , where promotion to higher ranks and departmental/institutional leadership roles is possible. In non-academic practices, other promotion opportunities include partnership, board representation and other distinct leadership positions. There is increasing emphasis in medicine on promoting diversity in higher ranks and leadership roles. One barrier is the pathway for advancement, with higher academic ranks and leadership positions historically being held primarily by White men given their disproportionately overall higher representation in medicine [10, 11] . While at one time this reflected the general makeup of medicine, this has been slowly changing with an increase in number of female physicians, as well as the highest female medical student enrollment of all time, currently at more than 50% [12] . However, female representation decreases with every higher academic rank, as well as with leadership roles, in institutions/departments and national societies.

Multiple contributory factors have created this scenario. Studies have shown that men create different networks than women [13] . Men usually network with those similar to themselves; therefore women do not have the same access to people in power or authority (usually men). For instance, networking activities including after-work social activities and dinners might not be feasible for women to attend given that they are more likely to be primary caregivers in the home [14] and have non-work-related obligations precluding their participation. In addition, the overall lack of women in higher academic ranks and leadership roles contributes to the lack of role models with similar backgrounds and challenges as younger female physicians [15] . There is a disparity in the lack of women in the positions to be "experts" or in influential roles as leaders. This is partly a result of some women themselves believing they need to meet all qualifications for a role rather than believing they have the skills to learn the tasks in the role, like their male colleagues tend to; in addition, men more openly self-advocate and promote their work than women [16] . The impact of female academic advancement has been exacerbated since 2020 because of COVID-19. Initial studies have shown that academic productivity and advancement for women have suffered because of new challenges in this pandemic period [17] [18] [19] , with the long-term effects yet to be determined.

Another important factor that is crucial to address is female physicians being subjected to discrimination and harassment, either openly or subtly, more so than their male colleagues. Discrimination might not be overt but rather a bias against a trait, whereas harassment is when one makes another uncomfortable with words or actions, such as unwanted sexual attention. It can either be directed at an individual or be present in a general form in an environment. Thirty-six percent of women physicians report harassment in their career [20] and 50% of female faculty and students experience sexual harassment in academia [21] . A recent study among female radiologists found that 60% of respondents reported being a victim of sexual harassment and 84% a victim of gender discrimination in the workplace [22] .

Similar to general trends in medicine, pediatric radiology has had a lag in advancement of women in academic ranks and leadership. However, given the near-equal gender makeup of Society for Pediatric Radiology (SPR) membership, there is opportunity to close the gap. The most recent survey data in 2021 showed that the SPR has 43% female members, making the gender difference in overall membership minimal [23] . This is significantly higher than the 25% female representation in radiology overall [24] . Despite the nearly equal gender representation within SPR membership, SPR leadership does not represent this. Gender differences in SPR leadership are more apparent, with more than 80% of SPR presidents being men since 1958 (the inception of SPR). More recently, with rising diversity, equity and inclusion initiatives, more women have served as SPR presidents/presidents-elect in the last 5 years. The SPR Board of Directors, another metric of SPR leadership, had the highest female representation in 2019 at 45%. The Society of Chiefs of Radiology at Children's Hospitals (SCORCH) has had an overall increase in female membership over time, with 33% of the members being women in 2021. This trend is better than that of the Society of Chairs of Academic Radiology Departments (SCARD), which only has 17% of department chairs being women [25] . However, SCORCH has had only one female president since it began in 1988, only in place in 2018-2019 [9, 26] .

Leadership should mirror the makeup at an institution, organization or department. There needs to be emphasis on creating a pathway for those with diverse backgrounds, which includes appropriate advocacy. Mentorship and sponsorship have been the traditional models of promoting career advancement. However, allyship is a crucial additional component to promoting diversity in academic advancement and leadership. This is especially important in pediatric radiology given the significant number of women who could advance with the allyship of their male colleagues.

Education Self-education is important to understand barriers and stigmas that can limit certain groups from rising. It is not enough to ask others their experiences -this puts the burden on the under-represented to educate others, which creates both emotional and cognitive labor for those doing the explaining. Allies take time to educate themselves -to read, listen, watch and deepen their own understanding. Ask for permission before broaching a topic that might be challenging for someone to discuss. Listen before speaking and asking questions. Approach the discussion with humility and a learning mindset. Recognize that all individuals' experiences are not equal -for instance, a White woman's experience will be different from a Black woman's from a trans woman's. It is important to be open-minded and not relate others' experiences through the lens of your own experience [1] . It is important to realize that others might be mistrustful of an ally's intentions given their prior experiences and deep-rooted skepticism; be aware of this but listen to their journeys, learn from their perspectives and build trust.

To be an effective ally, one needs to honestly reflect and recognize inherent advantages and resources that one might take for granted, that are not as accessible to others. Privilege has many connotations and does not only refer to tangible traits, such as wealth or titles, but also more subtle attributes, such as dominant gender (male) and race (White). For example, men are not asked about children or family obligations when considering escalating work-related responsibilities, as is commonly part of the thought process when considering women for the same roles (subconsciously or overtly). Another example is code switching -the need for women to change appearance and speech to fit into different settings and cultures. This is especially true for women of different races and ethnicities. An ally needs to acknowledge these differences, regardless of how uncomfortable or challenging it might be. Be open to feedback and be prepared to receive criticism, to be accountable for mistakes, and to recognize this as an opportunity to learn and do things differently [4] .

To be an effective ally, it is important to be aware of others' experiences in gatherings and meetings and to speak up if something inappropriate is being said. It is also important to be able to read nonverbal cues -does your female colleague look uncomfortable, frustrated, disappointed? Pay attention to who is being included, who is in the room, who is speaking. Is your female colleague being quiet and holding back because she might be the only woman in the room? Is she being interrupted frequently or not being given the attention or credit for her thoughts and contributions? Notice sexist words or statements that can be derogatory and hurtful. The key is not just to recognize these experiences and statements, but to speak up -if you see something, say something. This can be challenging. Self-education and awareness are essential but insufficient by themselves; it is crucial to be a vocal advocate.

Gaslighting is a phenomenon defined as "psychological manipulation that creates doubt in the victims of sexist or racist aggression, making them question their own memory and sanity" [1] . This can be expanded to include various types of derogatory aggression, such as political contexts or discrimination regarding ableism. Examples of gaslighting include someone telling a person who is experiencing these aggressions the following: "You are being too sensitive" or "He is just like that -don't be offended." These statements invalidate another's experiences. It is important for an ally to recognize this and intervene, even if the offended person is not present.

At many situations, women are one of a few, or the only, in a work situation, such as a meeting or even in an entire department. This can lead to undue pressure to perform better or to be on guard, and to being subjected to more bias and discrimination, leading to a sense of loneliness and being left out [27] . These situations emphasize the importance of inclusion and belonging in the workplace. Women need to be able to have a voice and to have that voice heard, regardless of whether they are the minority. It is important for male colleagues to act as allies in ensuring that female colleagues have this voice and are included in discussions and decisions. Creating an inclusive workplace allows female physicians, who might have been overlooked or inherently biased against in favor of their majority male colleagues, to highlight their strengths and assets, which otherwise might have gone unrecognized. Just as important as speaking out against aggressions and discrimination against female colleagues, allies should work to ensure that female colleagues are treated as equal members of the team.

Follow-through is crucial to foster women's advancement in pediatric radiology. Many men might be aware of the underlying issues hindering women's advancement, but they need to take action to make a sustainable change. It is important to advocate vocally for female colleagues and to sponsor them for new opportunities. Men should acknowledge their women colleagues' skill sets and capabilities and encourage them to apply for roles and ask for opportunities. Being proactive can be challenging for women in a male-dominated field; however, having male supporters can help. It is important, too, for those in power and in leadership roles to use their status to help advocate for others -this is the core of allyship.

Although gender equity in pediatric radiology has improved over time, there is room for progress, especially among higher academic ranks and leadership roles. As part of an intentional and concerted approach to change this, it is important to have a shift away from the historically maledominated culture of medicine and instead have men use their established privilege and power to act as allies for female colleagues. This is not just the responsibility of an individual ally; rather, it needs to be incorporated into departmental and institutional values to end the gender gap in pediatric radiology and to create female physician leaders for the future.

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