While women comprised 42% of all US medical school faculty in 2019, BIPOC women represented only 15% of all faculty, and URM women represented only 6% of all faculty . The percentage of BIPOC women among women faculty by race/ethnicity was as follows: 20% Asian, 5% Black, 3.4% Hispanic, 2.5% multiple race Hispanic, 2% multiple race non-Hispanic, and less than 1% identified as American Indian/Alaskan Native or Native Hawaiian/other Pacific Islander . From 2010 to 2019, the representation of Asian women among all female faculty has only increased by 3%, while the percentage of Black female faculty did not increase . Although there are more BIPOC women in medicine than ever before, they are commonly in lower ranks and less likely to have tenure or leadership positions than White women . Further, URM women continue to be severely underrepresented as medical school applicants, matriculants, and at all academic ranks with progress that is slow or regressive and not proportionate to their respective populations [3, 7].
While all women are underrepresented in medical leadership, BIPOC, especially URM, women are more underrepresented than White women. In 2019, women represented only 19% of all US medical school chairs; yet, BIPOC and URM women represented only 24% and 15% of female chairs and 5% and 3% of all chairs, respectively . A 2016 review of 135 medical institutions underscored the lack of women in decanal leadership, representing only 15% of all deans. Further, women deans were less likely to occupy roles related to general, research, clinical, and corporate decision making; disproportionately fulfilled educational, mentorship, and institutional public image needs; and experienced decreased representation with ascending decanal status . Further, women represented only 18% of all US medical school deans in 2019, with only a 6% increase in representation as deans over 10 years . Data for decanal race/ethnicity was not readily available.
All women academic physicians face discriminatory practices, such as lower compensation, slower promotion rates, and inconsistent or non-comprehensive paid family leave policies [7,8,9]. Women medical researchers are less likely than men to receive independent funding or publish in high-impact journals [10, 11]. Women are less likely to be introduced by professional titles and are not well represented among prestigious awards or journal board and medical society leadership roles [11, 12]. Inequities are even greater when taking into account race, ethnicity, gender identity, and sexual orientation and are especially pronounced for BIPOC and LGBTQIA+ women, who must deal with significant structural inequality, bias, and oppression as they attempt to advance their careers.
Women’s Representation in Academic Psychiatry
While representation of women in academic psychiatry has increased among junior faculty, their representation declines at higher ranks, with women accounting for only 34% of full professors in 2019, the majority of whom are White . Table 1 shows the number and relative percentages of women among psychiatry faculty by race/ethnicity at each rank . In psychiatry, URM women continue to be significantly underrepresented at every academic rank . Further, while 23% of 2019 psychiatry chairs were women, BIPOC women represented only 6% of psychiatry chairs and URM women only 4% .
BIPOC women are more underrepresented than White women in terms of tenure. Among psychiatry faculty in 2019, there were 587 White men tenured compared to 281 White women, and only 19 Asian females tenured compared to 56 Asian men . Black and Hispanic women had more representation in tenured positions than their male counterparts who were also underrepresented; specifically, in 2019 there were 13 Black female faculty tenured compared to 12 Black males, and 16 Hispanic female faculty tenured compared to 13 Hispanic males . Still, a large proportion of Asian, Black, and Hispanic women were not on track for tenure at academic institutions that offer tenure track positions (543, 227, and 174, respectively) compared to their male counterparts (500, 110, and 135, respectively); AAMC data does not clarify or explain these differences . Clearly, BIPOC women are not keeping pace with the career gains of White women [3, 24].
Gender Salary Inequities
Significant gender salary inequities exist across the academic medicine career span. Still, empirical data is limited, especially when accounting for women’s race, ethnicity, and sexual orientation. In a review of department chairs (N = 1073) within 29 public medical schools, only 92 chairs (16.7%) were women, including six female and 25 male psychiatry chairs . Among all chairs, the unadjusted average difference in annual salary by sex was $79,061. After adjusting for term length, specialty, inflation, title, and cost of living, the salary difference was $67,517 . The salary difference by sex for chairs serving for more than 10 years was $127,411 . AAMC 2018 faculty salary survey data showed mean male to female compensation differences of 20% ($138,500) for all clinical science chairs, and 11% ($53,400) for psychiatry chairs in US medical schools . AAMC noted that although the faculty salary survey data may highlight national trends, critical data to determine equity such as time in rank and productivity are missing  (Table 2).
The 2018 AAMC salary survey results for clinical science physicians also showed sex differences in mean compensation, with men receiving higher compensation than women at all ranks . The compensation differences (gaps) between male and female physicians in academia were as follows: among all clinical faculty (clinical instructor,16%; assistant professor, 23%; associate professor, 24%; professor, 21%) and among psychiatry faculty (clinical instructor, 10%; assistant professor, 8%; associate professor, 9%; professor, 8%) . The overall gaps were wider than within specialty gaps for all specialties, possibly influenced by gender specialty choice . Since 2013, some gaps have narrowed, while others have widened . (Table 2) Faculty survey data combining sex with race/ethnicity was not readily available. Further, women researchers are impacted by gender inequities in funding, career development awards, and start up packages [8, 16].
Available research suggests that salary inequities remain when controlling for age, specialty, hours worked, productivity, academic rank, and practice characteristics, with greater gaps for BIPOC and older women [11, 17, 18]. BIPOC women face structural inequities, particularly Black women, who have the greatest inequities in compensation, and generally have less familial wealth than White women, influenced by the Black—White wealth gap and other factors related to structural racism . For example, Black parents are twice as likely to be unemployed and unmarried and are significantly less likely to own homes and more likely to single parent than White parents . Between 2010 and 2013, annual median physician income adjusted for age, race, sex, hours worked, state of residence, and time period was $253,042 for White men compared to $163,234 for White women and $188,230 for Black men compared to $152,784 for Black women . The interaction of characteristics such as sexual orientation, race/ethnicity, and gender identity have a compounding effect on salary inequities, yet are frequently omitted from salary discrepancy statistics , limiting our ability to cite empirical data. Still, less income during their working years will leave women with less retirement income, including social security and pension benefits .
Within academic medicine, BIPOC women remain significantly more disadvantaged compared to White men and women and encounter compounded biases and barriers that thwart their advancement as they expend time and energy proving their authority and competence while simultaneously disproving harmful stereotypes . This remains true in academic psychiatry. For example, a Black female psychiatrist, Dr. Baker, described experiencing racial slurs and other bigoted behavior, while White superiors silenced any exploration of racism . While colleagues perpetuated harmful race-based generalizations about Black communities and their association with poverty and mental illness, Dr. Baker was forced to remain silent and expend time and energy addressing racist claims . This example of navigating academic psychiatry while both Black and female further underscores the complexities of survival and career success for women with multiple minoritized statuses.
Prior research has documented women’s susceptibility to stereotype threat (i.e., the anxiety faced when one is evaluated by negative stereotypes ). In a study in academic medicine, women junior faculty reported more vulnerability to stereotype threat, sensitivity to rejection, identification with their gender, feelings of lower relative potential, and a lower sense of belonging than their male counterparts .
BIPOC and LGBTQIA+ women are susceptible to stereotype threat and face unique challenges such as managing their visibility in organizational contexts in which they inhabit multiple minoritized statuses. Minoritized women risk becoming more visible because of their racial, sexual orientation, and gender differences rather than for their competence, character, or achievements . Conversely, women trying to blend into the dominant narrative risk are becoming chronically invisible, silencing their achievements and contributions . In addition, BIPOC and LGBTQIA+ women must navigate negative climate and culture characterized by racialized and sexist stereotypes at work, balancing frequent misperceptions of being perceived as aggressive or angry or not assertive enough, further silencing them . This phenomenon is described as a double bind or jeopardy , which is even more compounded by feeling obligated or pressured to represent the minority perspective . All women may experience sexism, bullying, and institutional roadblocks, but BIPOC, especially URM, and LGBTQIA+ women, are often more isolated and under-respected because of discrimination, tokenism, and the lack of diversity [13, 23,24,25,26].
Harassment and Discrimination
Women academic physicians of all identities are known to experience discrimination, gender-based harassment, unwanted sexual attention, and sexual coercion at an alarming frequency, even more so for BIPOC and LGBTQIA+ women [27, 28]. A study of 5782 physician mothers found that 2/3 reported gender-based discrimination and 1/3 reported maternal discrimination, defined as discrimination due to pregnancy, maternity leave, or breastfeeding . Salient examples of such discrimination, exacerbated for BIPOC women, include lower likelihood of being hired, promoted, or offered a leadership position [25, 30]. LGBTQIA+ women must face stigmatization, marginalization, and residency and job placement discrimination . In prior studies, more than 50% of women faculty and staff in academic institutions reported harassment, commonly gender-based, perpetuated by faculty (superiors and peers) and patients, among others [27, 28]. Despite all women being susceptible to multiple forms of harassment, the experience between cisgender White women, BIPOC, and LGBGTQIA+ women are distinct .
BIPOC and LBGTQIA+ women are known to experience elevated rates of harmful overt and covert forms of overlapping oppression, harassment, and discrimination. These interdependent and compounded forms of oppression are deeply embedded in administrative and educational policies and practices, hindering women’s progress and acting as mechanisms of social control [27, 28, 31]. LBGTQIA+ women face unique challenges as part of heteronormative cultures that are negative and invalidating. For example, LGBTQIA+ women physicians report being denied referrals and experiencing social ostracization while also experiencing delayed promotion, loss of practice or income, and negative stereotyping . These inequities often include various forms of harassment, derogatory comments, and humiliation.
Additionally, one study found that BIPOC women in the sciences experienced more harassment (combining racial and sexual harassment) than White women, White men, and BIPOC men [28, 32]. Specifically, BIPOC women experienced more verbal racial harassment than other groups and equal rates of verbal sexual harassment compared to White women [28, 32] Further, LGBTQIA+ women experience higher rates of sexual harassment than heterosexual and cisgender women .
Research has documented that BIPOC and LGBTQIA+ women are less likely to report harassment than White women, due to fear of negative outcomes, retaliation, and beliefs that perpetrators will not be reprimanded [13, 27,28,29, 31]. Finally, women are not homogenous with mutually understood experiences. The differences in harassment and discrimination experienced by minoritized women remain unrecognized by White women, delegitimizing their experiences and perpetuating marginalization [13, 25].
Microaggressions and Bias
Microaggressions can be described as “brief and commonplace daily verbal, behavioral and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group” . Microaggressions are not limited to race and are influenced by other minoritized statuses, such as ethnicity, gender, and sexual orientation. Microassaults, microinsults, and microinvalidations are subtle forms of oppression often more insidious and difficult to identify, further creating an impossible bind for BIPOC and LGBTQIA+ women who experience any variation of gendered, anti-gay, or racialized oppression . Gender-based microaggressions predominately impact women, especially BIPOC and LGBTQIA+ women, in academia through three social mechanisms: gender blindness, gender-stereotypical assumptions, and sexual objectification .
Explicit and implicit bias (also known as unconscious bias) against women, including those with minoritized statuses, in medicine are well-documented and adverse factors in all career stages [13, 23, 25, 30]. BIPOC women are recipients of automatic assumptions about their abilities and ambition; their work is often undervalued [13, 34]. Professional credibility and authority may be challenged regardless of their competence or ranking [13, 31]. BIPOC women, especially Black women, commonly feel unsupported in medical school, while domestic born BIPOC women may hold fears based on perceived biases or xenophobic attitudes in clinical settings . Asian-American women may fear being perceived as too young to hold the proper credentials . These concerns translate into behavior and appearance changes, e.g., Muslim women stop wearing hijabs for fear of explicit and implicit bias related to Islamophobia . Thus, implicit and explicit biases operate as a discriminatory form of social control. Additionally, such bias in psychiatry can be particularly troublesome as it likely influences students and trainees’ assessment of presenting issues among ethnic and racial minoritized patients . Taken together these findings may be correlated to the elevated rates of stress felt by BIPOC and LGBTQIA+ women .
BIPOC faculty experience a phenomenon referred to as the minority tax which is defined as additional responsibilities and burdens placed on minoritized persons. They feel beholden to address racism, diversity, mentorship, clinical responsibilities for underserved populations, isolation, and promotion inequities . Minority tax disrupts scholarly productivity by diverting a minoritized faculty’s time to addressing systemic and structural problems, which are beyond their control . Minority tax burdens are frequently experienced by those who are often isolated and may be one of few faculty members with a minoritized ethnic or racial identity . Examples of minority tax include the following: designation as representative spokespersons for their racial group, assignment to offsite clinical work locations to serve health needs of marginalized communities, mentorship of a diverse cadre of students with inadequate mentorship, and assignment to institutional diversity efforts, often without compensation . Minority tax is broad and all-encompassing and is harmful because it is inextricably tied to one’s minoritized status, and often unfairly requires unrecognized and uncompensated labor .
Impostor syndrome is a psychological phenomenon, first described in high achieving women  that refers to a pattern of behavior wherein people doubt their abilities and persistently fear being exposed as a fraud, despite evidence of their success [37, 38]. It is encountered in high stakes professions, including medicine and academic psychiatry. Some studies suggest higher severity in women faculty, especially BIPOC, due to added pressures to perform against racial and gender stereotypes and discrimination [13, 39]. While men tend to own success as an inherent quality, such as being smart or creative, women may discount their success by stating that they worked hard or were lucky [37, 39].
A 2016 report showed that out of 138 medical students, 50% of female and 25% of male students were affected by impostor syndrome, which was less prevalent among White and Asian medical students than other race/ethnicities (30% vs. 73%) . A systematic review of imposter syndrome among college students underscored a high prevalence among Black, Hispanic, and Asian students . BIPOC, especially URM, students may be predisposed to imposter syndrome due to increased stress from sociodemographic, familial, and environmental factors, including racial discrimination and enduring negative stereotypes [38, 39]. Impostor syndrome is correlated with anxiety, depression, burnout, physical exhaustion, and avoidance of tasks with high prominence [38, 39]. It has been associated with perfectionism, is a strong predictor of psychological distress, and may not abate with more years of training or experience [38, 39].
Lack of Mentorship/Sponsorship
Mentorship and sponsorship are integral components of one’s career advancement , yet male physicians are more likely to receive mentorship or sponsorship than females or BIPOC [42,43,44]. Women are also less likely than men to have mentors/sponsors in power positions, which reduce their access to career-promoting opportunities. Further, the majority of institutions lack specific programs targeting women and BIPOC [42,43,44]. URM faculty especially rely on mentorship for success, yet the lack of representation of senior URM faculty translates into mentorship remaining a barrier to recruitment, retention, and advancement . Further, sponsorship is important for the advancement of URM women into leadership roles, as they may be more subject to implicit bias and discrimination than their White counterparts [20, 22, 23].
Work Life Integration
Work life integration with domestic and caregiving responsibilities creates barriers and challenges for women’s advancement. One report found that childbearing leave (i.e., for birth mothers) and paid family leave (i.e., for post-birth or non-birth parents) policies are inconsistent across top medical universities . Although all twelve universities studied provided childbearing leave, only three provided full salary support for more than 8 weeks and only eight allowed extensions . The mean paid family leave duration was approximately 18 weeks; only four universities provided more than 8 weeks of full salary support . Parental leave during residency creates further barriers due to minimum training requirements and difficulty obtaining fellowship and academic positions “off cycle” . Additional barriers arise upon returning to work as child care and lactation support can be nearly impossible to find even though the USA guarantees breastfeeding breaks [46, 47].
These challenges are more complex for URM women, who may be first-generation college or professional school graduates, may be supporting their families of origin including their own, and often have less familial wealth by which to establish financial stability, especially Black women, as described previously . Further, only half of Black college graduates in 2014 were married compared to 59% of Hispanic college graduates, 68% of White college graduates, and 74% of Asian college graduates, and those who marry have more marital instability than other groups, known as the Black Marriage Gap . These findings underscore how inconsistent and rigid policies may pose additional challenges to the retention of women and primary caregivers, especially URM, in the workforce and further explain the gender wage gap .