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Inclusion of women as a diversity measure

The changing ways in which women have been included and studied at Yale School of Medicine over the years is a useful gauge of progress.

Carolyn M. Mazure
Carolyn M. Mazure

When we think of diversity at an academic medical center, our focus tends toward reviewing the composition of our faculty, students, and staff, and ensuring that our academic community is broadly representative of our population at large. In addition to inclusion of “the many” being the right thing to do, diversity fosters a more creative and productive working environment.

To build diversity within our school, one goal has been to increase the number of faculty members who are women; and over many years, the school has considered how to make the environment more welcoming to women and supportive of their academic careers.

In 1988, for example, Dean Leon Rosenberg, MD, HS ’63, formed a task force to design a plan for increasing the number of women at all faculty levels. The task force report indicates that as of 1988, “Many people in academia assume that discrimination against women has ended, since there has been a significant increase in the number of women students, house staff, and junior faculty in recent years.” As evidence of this at YSM, 1988 data are provided to show that 33% of our entering class of medical students were women. Yet, as this thoughtful report also points out, “women occupy only 7% of the total tenured faculty of 254 …,” and the change in the number of women entering the medical community has been due “in part to the enactment of anti-discrimination legislation in 1964.” The report concludes that women remain underrepresented, and identifies a “perception bias” about how women perform as faculty that holds back their full inclusion.

There is much more to this careful report and numerous subsequent reports, such as the 1994 Report of the Dean’s Task Force on Senior Women in the School of Medicine constituted by Dean Gerard Burrow, MD ’58, HS ’66; the 2003 Report from the Commission on Women Faculty, requested by Dean David Kessler, MD; the 2015 Ad Hoc Task Force on Gender Equity, and others focusing on various aspects of gender equity. Each has marked renewed effort in advancing the metrics of change, and these metrics now show that over half of our entering medical school class are women and a quarter of tenured faculty are women.

However, these more recent metrics do not obscure the significant challenges that remain. And here we turn to a common thread initially reported by the 1988 task force and reflected across subsequent reports. This thread is the notion of a perception bias about women, a bias which must be countered by gathering objective data that show the many and varied contributions of women faculty.

This struggle for inclusion of women extends to whom we study and for whom we develop our treatments and prevention strategies. In research, there has been a perception bias about the need to study women.

It was not until the 1993 NIH Revitalization Act was implemented that the National Institutes of Health required that women be included as study participants in NIH-funded studies. Prior to that time, the prevailing tradition was not to include women in clinical trials or analyze data by sex or gender, leaving an enormous gap in our knowledge about the health of women.

Of the three main reasons for excluding women, one revolved around the commitment to protect women from experimental risk that could adversely affect childbearing. Though an important goal, this restriction for inclusion as a study participant became broadly applied to women. The Institute of Medicine’s study on ethical and legal issues on the inclusion of women found that protectionist policies did not account for all inattention to the study of women’s health and concluded that inattention also arises from biases that permeate society and science. The second reason women were generally not included was predicated on the misinformation that women are less affected by many health conditions and, if affected, syndromes and responses are the same across genders. Finally, women were often not included due to the “complexity” that hormonal variation brought to a scientific study. Yet, this raises the question—doesn’t this variation, as well as other sex-specific factors, actually require the study of both women and men? To be sure, some studies included women if a condition is unique to women, such as reproductive cancers, or if a condition is highly prevalent in women, such as depression. However, in these latter studies, data were not analyzed for sex or gender differences, again leaving an important knowledge gap for women and men.

Women’s Health Research at Yale (WHRY) was founded in 1998 to ensure a leadership role at YSM in remediating these gaps—knowing that, as indicated by the American College of Physicians, women are more likely to suffer from chronic diseases and disability as well as acute and chronic pain, die following a heart attack, develop depression and anxiety, have autoimmune diseases, and develop Alzheimer’s disease.

Since its inception, WHRY’s goals have been to ensure women’s lives are advanced through research and its clinical translation; share new findings with the public to inform personal health decisions; and promote the study of difference between and among women and men to enhance the well-being of all. Moreover, WHRY’s goals include setting the stage for important discovery in basic science by always including females in studies using vertebrate model systems, as now required by the NIH. With these goals in mind, WHRY has initiated new studies and research collaborations, and funded over 100 faculty projects from 19 YSM departments, sparking innovation and productivity in uncovering new findings on pressing health concerns for women ranging from cancers to cardiovascular disease.

For example, WHRY-affiliated Yale investigators have uncovered metabolic and signaling pathways for a colon cancer prevalent in women, differential effects of stress on neurodevelopment in adolescent girls and boys, a new treatment for autism in girls, an innovative therapeutic “prime-and-pull” vaccination strategy to prevent sexually transmitted infections and cervical cancer, and a more effective taxonomy for identifying acute myocardial infarction in women—among many other useful and meaningful discoveries. Importantly, our funded investigators subsequently have generated over $100 million of new research grants to pursue the research they have launched with WHRY support.

Maintaining the trajectory of progress in studying women and sex/gender differences requires believing there is value in diversity and retiring the notion that difference means better or worse. The metrics of diversity are important in assessing our progress, but fundamentally diversity is about perspective. Teaching the next generation of investigators and clinicians about the value of diversity and modeling inclusiveness is what will secure progress for human health and our scientific future.