Equity Is Everyone’s Business

Ethier et al shone a spotlight on 2 key areas within transplantation: gender and geographical disparities in access to professional development opportunities.1 These mirror the disparities in patient access to and outcomes after transplantation, and it is likely that the 2 are linked. One focus of this article was the gender gap in authorship of abstracts presented at The Transplantation Society (TTS) meetings from 2016 to 2022. It demonstrated that 39% of the first authors and 24% of last authors were women. This is in keeping with literature from other specialties.2 In addition, authors highlighted that most abstracts presented emerged from high-income settings (71%) and that, within the 29% from low-middle income countries (LMICs), the proportion presented by women declined significantly. The authors conclude that lack of resources and systemic gender inequities are likely to limit career development and progression of women and researchers from LMICs.1 It is only recently that attention has been given to sex-specific outcomes in a range of common diseases, such as cardiovascular disease.3 There is increasing understanding of different outcomes after transplantation between male and female sexes, with female sex having worse outcomes in both children and adults, and such work has been led predominantly, but not exclusively, by female researchers in various geographical regions.4–6 At a recent state of the art meeting on sex and gender in transplantation: the female perspective, a female transplant recipient described many of the challenges for women after transplantation, relating to reproductive health, and to a lack of understanding about their role as carers posttransplant.7 It is imperative that healthcare professions reflect the patients they serve. In the United Kingdom, only 16% of consultant surgeons in all surgical specialties are women, and in transplant surgery, the percentage is even lower. Clinical academia presents a particular challenge for women: in the United States, women represent only 41% of faculty in academic medical centers, despite constituting >50% of medical undergraduates. Women are significantly less likely to hold leadership positions. Only 25% of such positions including department chairs and deans are headed by women.8 Therefore, it is difficult for younger women to aspire to these roles: “You cannot be what you cannot see.” The challenges are substantial: there are societal expectations and viewpoints, with an expectation that women are carers within the family, and this is particularly pertinent in LMICs. Major attitudinal challenges remain, with implicit bias and sexual harassment of women in predominantly male working environments, which are barriers to progress and may lead to women leaving the profession rather than being subjected to such treatment.9 Publications such as this one are key to raising the issue, and several important papers on this topic have been published by Transplantation and other journals. TTS made a commitment to the female transplant community in 2004, when Professor Kathryn Wood became its first female president and set up the Women in Transplantation (WIT) initiative, which remains active today. There are 3 pillars: advancing and inspiring female transplant professionals, championing issues of sex and gender in transplantation, and advocacy for equity in access to transplantation and donation. Research grants are available for projects on sex and gender for applicants from LMICs, and most recently, specifically designed to address sex and gender inequities among indigenous peoples undergoing solid organ transplantation. (https://www.tts-wit.org/research-grants/wit-2025-2027-research-grants-awards). WIT offers awards for women leaders in transplantation, and unsung heroes, ensuring visibility for women, as well as providing a list of female subject matter experts as potential speakers for congresses (https://www.tts-wit.org/). More is required, and it must not be the business of female transplant professionals alone. We seek the attention and commitment of all transplant clinicians and academics to provide support and encouragement to everyone interested in a career in transplantation, irrespective of sex, gender, and geography. But what does that mean? Each of us carries unconscious biases, of which, by definition, we are unaware, and it is beholden on us to reflect on these in our daily interactions with colleagues and patients. To address the specific concern raised, attention must be focused on the optimal way to deliver large scientific conferences, which are costly, require travel abroad, and are likely to negatively impact women with caring responsibilities and those from LMICs. Financial and other constraints make this challenging for such individuals, who would be available to present remotely, as reflected in a higher percentage of women presenting during TTS online in 2020.1 Conferences do, however, have benefits in terms of networking and development of scientific collaborations. Scientific programme committees must consider gender balance in the invited speakers, panel members, and chairs to ensure that women and those from LMICs are represented and recognized for their excellent contributions. More travel grants for those presenting from LMICs would be beneficial, as well as provision of funding for training and mentoring. There is no doubt that effective mentoring can provide support and practical encouragement for women and those in LMICs, but the establishment of such international programmes is a logistical challenge, with barriers in language and time differences. Targeted sponsorship offers specific research or clinical opportunities but requires significant investment from sponsors and is challenging to scale widely. Several commentaries have been written on gender equity in transplantation, and Transplantation has demonstrated its role in advocacy through such publications.7,10 How can this be translated into real improvements in access to transplant careers for women across the world to the benefit of patients and science? Advocacy for equity for all in transplantation is key and could take the form of plenary sessions at major transplant congresses, a focused edition of a transplant journal to highlight the challenges, as well as more strategic advocacy at societal and governmental levels. WIT is a leading light in advocacy for women and for disadvantaged communities; ongoing support for WIT is essential. Ensuring that transplant professionals represent the communities we serve will impact on patient experience and outcome and is the responsibility of all.