Is There a Culture of Shame and Stigma in Infertility?

A national survey of more than 1,000 female oncologists explores their difficult career choices amidst attempts to build families, their concerns about fertility, and their issues with discrimination during pregnancy and/or maternity leave. Dr. Fumiko Chino, Dr. Anna Lee, and Dr. Erin Gillespie discuss the survey's findings and share their own insights and experiences as female oncologists.

TRANSCRIPT

Dr. Fumiko Chino: Hello, I am Dr. Fumiko Chino, a radiation oncologist and health equity researcher at Memorial Sloan Kettering Cancer Center and the guest host of the ASCO Daily News podcast today.

In today's episode, we'll explore gender equity within the oncology workforce. Our discussion is centered on a newly published article in JAMA Network Open.

This national survey of over 1,000 female oncologists found that 95% considered their career when planning a family, and about one-third faced fertility concerns when trying to become pregnant. Additional findings include that one-third faced discrimination during pregnancy and/or maternity leaves.

Joining me for this discussion are study team members Dr. Anna Lee, an assistant professor in radiation oncology at the University of Texas, MD Anderson Cancer Center, and Dr. Erin Gillespie, an associate professor in radiation oncology at the University of Washington and a member of the Hutchinson's Institute for Cancer Outcomes Research.

Our full disclosures are available in the transcript for this episode, and disclosures relating to all episodes of the ASCO Daily News podcast are available on our transcripts at asco.org\podcasts.

We have all agreed to go by our first names today. Anna and Erin, it's great to have you on the podcast today.

Dr. Anna Lee: Thank you, excited to be here.

Dr. Erin Gillespie: Yeah, thanks so much, Fumiko.

Dr. Fumiko Chino: Well, I'm hoping to just dive right in to talk about this study, which I was proud to be on the authorship team with both of you. I just want to give a little bit of setup about how this study started, which was essentially within our own group of junior female faculty.

We have semi-regular meetings, and this idea for the study actually came up at a picnic for some young female faculty members. That then led to a small survey that I did on a Facebook group of young female oncologists and then, ultimately, to the national survey. So, Anna, do you mind telling me just a little bit about your research background and why this topic is important to you?

Dr. Anna Lee: Yeah. So, when I was a resident along with my co-resident Virginia Osborn, we helped co-found a group called the Society for Women in Radiation Oncology, or SWRO. We were able to bring a group of women in our field who were interested in looking at the experiences of female radiation oncologists, both starting at the residency, the training level, but also into practice. And we had generated an initial survey looking at women's experience, and they found that even though the majority, almost 95% of women, felt like radiation oncology was a family-friendly field, only about half of the group actually felt that it was after their lived experiences. So, this kind of led me to being interested in participating in the development of this study.

And personally, I have been going through the fertility journey myself. My partner and I got married last year and, you know, you think that for so long you put an effort into something and get a result and just how I did in academics or in terms of my career aspirations, you think that it'd be very straightforward, but it's been more of a challenge than I expected, and we are going through the whole workup process and considering our options. So this is a study that is of personal interest to me.

Dr. Fumiko Chino: Thank you so much for sharing that. And Erin, do you mind just sharing a little bit about your background and why this topic is important for you?

Dr. Erin Gillespie: My research really focuses on access to high-quality, patient-centered care. I'm from Anchorage, Alaska, so this idea of variation in quality and differences in care people receive has been central. And one thing that I've noticed over time is that the physician workforce has such an important—and physicians, in general, in oncology—have really big impacts on the care that patients receive.

And in radiation oncology, we've seen for many decades now that we have only about 30% of our workforce is women. And to Anna's point, why is that? And I think this study sort of gets at some of the challenges that women may be foreseeing in entering an oncology career.

For me personally, I started my first faculty position in my mid-30s. And it being a small field, I've moved around every few years from the best academic medical school to residency to a faculty position. And you know, in my mid-30s, I wasn't in a stable, long-term relationship, so I, as you were describing, went through the fertility preservation process and got to be fortunate to have a group of junior women faculty, like you, Fumiko, who would actually share and discuss. And it was in New York where all these discussions came to light, and in the actual fertility clinic, where you realize there's a lot of other career-oriented women with the same experiences.

And so, how does this general phenomenon potentially impact us in oncology and downstream are patients who—there have done some studies that gender and sex sort of concordance between patients and providers can impact the types of treatments that people are receiving, so I think it's very important. Thanks for inviting me.

Dr. Fumiko Chino: Yeah, I think that you bring up a really important point, which is that essentially when we think about equity issues, we're not just talking about access to high-quality care for patients, we're also talking about equity within our fields and within the workforce. And this concept of fertility research and gender equity within oncology, I think is, thankfully, rising in importance. And so, I was so happy to be able to be part of this study that looks at it.

But, I guess, my next question is, what are the real barriers to doing this type of research, and what are the barriers to actually improving gender discrimination like what this study shows? Anna, do you want to take that first?

Dr. Anna Lee: Yeah, sure. Well, there's certainly a strong amount of shame and stigma that comes along with infertility. Even being able to open up about it and share with your colleagues and go through a process that's very personal while you're working, but it kind of bleeds into or affects your day-to-day work life.

So, that culture and that inability to be open about it I think is really making it difficult for people to share and discuss it publicly, and also, I think that there's some level of perception that this should not be discussed in an academic environment. But the reality is that even our survey study showed that women certainly thought about their career when it came to family planning. And so the more we discuss it, the more that we normalize this kind of conversation, it will bring to light how women are being affected by their careers. And also, I think that with our survey being completely anonymous, it was able to be an avenue for women to be able to share their experiences too.

Dr. Fumiko Chino: Yeah, I know certainly I feel very privileged to have been at a large institution that really did have a very active and engaged group of young female faculty where I felt like almost protected by just numbers, for lack of a better term, and for us to be able to share our experience.

Now, Erin, have you noticed anything in terms of, for example, the motherhood penalty on career or productivity in terms of the capacity for even getting the optimal position for yourself? You mentioned a little bit about your own experiences coming from a small area in Alaska and how that really made you have to hustle hard for optimal career outcomes.

Dr. Erin Gillespie: I guess like when I think about—to Anna's point earlier, just having open discussion with people in the field, and like you said, being in New York, a fairly progressive environment and women are more open about these things early on, was definitely helpful.

What I've heard of a lot of people beyond the career-driven nature, and you know, there was this article from The New York Times several years ago that I remember talked about women that had kids between 25 and 35, never were able to catch up to their peers because those are kind of the really critical career development phase and like really establishing yourself and your independence, which always kind of sat with me and I always justified it. It's just like, "Well, I guess the fact that I'm getting to these things later may have career benefits because I'm not actually ready to go through all these things in residency."

And then, the other thing I've heard people talk a lot about in radiation oncology was the extensive oral boards, which just further—we do five years of radiation oncology and then there's another couple years, can be a couple of years of very intense studying and passing exams that used to be even more strictly timed. And so, people were literally delaying family planning in order to make sure that their jobs as a clinical radiation oncologist was safe and protected, and they could flourish in what they've spent their life working on.

So, I do think, back to Anna's point, that just starting these conversations and engaging the board of radiology on how to actually accommodate women, a lot of it comes down to accommodations to encourage gender equity.

Dr. Fumiko Chino: You know, one thing that was quite striking in our survey was just about essentially what people had to sacrifice in order to actually have kids, and this sort of patchwork formal paid family leave, and the fact that we really don't have a good national policy, and it's just very state- and institution-driven. And I know that Anna and Erin, you both actually each moved institutions within the last couple of years, moving from New York, which, as previously stated, is a pretty liberal state to your current institutions.

So, I was just wondering if either of you could speak about how even the fact that we don't have a national policy in this patchwork leaves women sort of at the whims, in terms of planning their career and their family planning, at the whims of wherever they end up. Anna, I know you did a little bit more background research on this, do you want to take that first?

Dr. Anna Lee: Yeah. Actually, when I moved out of New York to Texas, unlike New York where they have, I believe, it's a statewide policy for maternity leave paid, and we don't have anything like that here. But also, our insurance policy initially didn't cover OSI preservation or IVF. Recently, they do now cover that. So, I've been able to breathe a sigh of relief in knowing that I can start my journey in exploring these options and knowing that my institution supports me in that way by having that coverage. So, definitely having institutional buy-in allows us to have more freedom and flexibility and feel the relief in knowing that, "Okay, I can prioritize both my career and my personal life, and be able to support both, and have my career also support that part of my life."

Dr. Fumiko Chino: Erin, anything to add for that? Again, I know that you just moved institutions.

Dr. Erin Gillespie: Yeah. You know, it's interesting. When I was looking, my husband and I were actually not living in the same city. So, as we became pregnant, the desire to be in the same place became more real. But thinking about changing institutions was complicated, and ultimately, the state laws—you know, so, we learned about multiple states, and having state laws is helpful, although FMLA requires you to be in a place for usually about a year in order to qualify for any of the state benefits.

And so, what I ended up finding was that the institutions ultimately still played a huge role in determining if you wanted to change your career, that it was up to the institution to really support a maternity leave situation. So, while I think that the state can set like some general guidance that probably helps the culture, ultimately, institutions play a huge role.

I was actually just talking to one of my co-residents from UC San Diego, who is in a private practice in Anchorage, and he was asking me, "Are there any general guidelines in family leave for radiation oncology? Have you seen anything to help institutions, large or small, really establish best practices?" And I referred him to SWRO because I said if anybody knows of anything that's been drafted, it would be your organization. But I honestly don't think that there is anything, and I think that is a room for improvement.

Dr. Fumiko Chino: That really segues into our next topic, which is how do we really advocate for ourselves and our colleagues to improve the status quo? Because as it stands, it's phenomenal that we have landed in places that have both the insurance and the policy coverage for maternity leave and for fertility concerns, but I think a lot of our colleagues aren't so lucky.

Anna, do you want to take that first?

Dr. Anna Lee: Yeah. I think when it's available, both men and women should take family leave or paternal leave. Taking leave when either sex has a child, it kind of normalizes the fact that child care should be an equal distribution of work, and also that we need to value both men and women being at home to take care of the first few months of a child's life. So, once we have that, I think that when you improve the culture of an organization, it can automatically help support the institutional buy-in as well.

Dr. Fumiko Chino: Yeah, that whole "he for she," and it's hilarious to think that just men taking paternity leave when allowed really does—number one, they have more bonding with their new baby, but also, it makes it normal that everyone is taking leave because that seems appropriate, what's best for the family and also what's best for the individual person to actually have that time with their child.

Erin, additional thoughts in terms of how do we advocate for ourselves?

Dr. Erin Gillespie: Yeah. To that point, I will say I really applaud Memorial Sloan Kettering for having people like Sean McBride in our leadership that were young enough to really advocate for having paternal leave in addition to maternal leave and making that something that the junior faculty were like, you know, it's not just something that's possible, but should be expected. And so, I see an opportunity for institutions to really give leadership opportunities to kind of these junior, mid-level faculty that really can have a cultural influence on how people—not that every man in our department has taken that leave, certainly, but I feel like there is this need to change the culture because until men are actually taking significant leave, there is still this disparity.

Dr. Fumiko Chino: You know, I have to reflect kind of on my own role models. My mother had 5 kids in 6 years, as being a physician, a radiation oncologist. And in my mind now, as someone who is a radiation oncologist who has zero kids, I have no idea how she did it. I feel like it was so challenging for me to just build the career that I have.

So, I was just wondering, are there people that you can look to as role models? I think, honestly, Erin, you said Sean McBride, as you know, an active and engaged father, who is very open and speaks frequently of his, you know, daddy duties. Again, it's hilarious that I'm pointing to Sean as a role model, but he really is. I mean, that's part of his persona. Anna, do you have role models in terms of thinking about how to have that delicate balance in this idea of like you could have it all?

Dr. Anna Lee: Fortunately, I have so many peer mentors, and friends, and people in the field going back to residency, seeing my co-resident, Virginia Osborn, going through training, having 2—she had 2 kids during training, and then, you know, seeing even faculty here having children early in their mid-career, just being able to balance everything, and making sure that they really understand the policies of the institution so that they're taking what they can in terms of their leave and their benefits.

So, I think that they're showing me that we don't need to be apologetic about taking leave. We don't need to necessarily ask our colleagues or be apologetic to our colleagues or to our institution for taking leave because it's a part of our life, it's a part of our fabric, in terms of being able to have children and raise them. And if that's something that one wants in their personal life, I feel like it's something that is, obviously, going to affect both their careers, but the career will affect their personal life, and being able to achieve both of those is something that we can all strive to help each other.

Dr. Fumiko Chino: Yeah, absolutely. And I think, honestly, it's great to have role models and people who are, you know, working to make the environment better in terms of gender equity. I think one of the most surprising findings from this study was that, actually, there was a minority of women who actually felt discrimination during pregnancy and maternity leave that actually came exclusively from other women.

Erin, do you have any comment on that? Is that reflective of anything that you've seen?

Dr. Erin Gillespie: Yeah. This issue of there is still ongoing challenges of the idea that women discriminate as much or more against women. When I look back on my own mentorship, I've actually had mostly strong male mentors, and they were as family-oriented and work-life balance. I mean, Jim Murphy, as a resident, and then Justin Bekelman, as a faculty member. They've always been very imperative that your personal life is a high priority and that you don't necessarily sacrifice that. And to do that, you have to be smart about the commitments that you make and how you balance these things.

But despite that, one of my mentors recently said, you know—and men can give great advice, and they can certainly advocate, and I think it's critical that they provide that. But one of my mentors recently said, "Ultimately, as you enter this new phase of being a mother, you need to find really close, strong, women mentors that have actually been through this because their experience is just not the same. As much as we can talk the talk, there is still a fundamental difference, and mentorship on both sides is critical."

Dr. Fumiko Chino: Absolutely. Wrapping up this podcast, do you have any other final thoughts, either Erin or Anna, about our findings on how we can continue to make sure we're making improvements for ourselves but also for the field?

Dr. Anna Lee: I am encouraged, though, that I think we're seeing incremental improvements in our field. You know, I can't speak on all of oncology, but in radiation oncology, even the timing is more flexible. We're able to be boarded through Zoom, and we don't have to travel to a single site.

So, I think that we are seeing incremental improvements and there's a lot of, now with both the Society for Women in Radiation Oncology, but we have Radiation Oncology Women Physicians' Group, we have different groups that are advocating and making sure that our voices are heard and that, you know, our voices also are translating into policy level changes.

And so, we still don't have national level, or I don't think we have blanket society-level recommendations for maternity leave that we can refer to, and I don't think all institutions are adopting them universally, but I think that there's a growing course and a growing movement of people kind of advocating for that, and we're inching towards that slowly, but surely.

Dr. Erin Gillespie: Yeah. And I think that to that point, just the thing that I've tried to change in my own practice has been to normalize the conversation because going back to what I said, moving to New York, it was a normal conversation that you talked about these things, which hadn't been the case before. And so, you know, with my medical students, residents, I'm very open about what are some challenges, but what are the solutions and how do you balance these things, so that they feel like this doesn't have to be something that you suffer, or think, or worry about without there being people to talk to.

Dr. Fumiko Chino: No, I think that was a really true concept and the idea of like—I know when I was on my interview surge, I was told, "Don't ask about the maternity leave because future employers are going think that you're trying to get everything out of them." But the idea that we shouldn't even ask about it, it seems insane, so I'm glad we're moving forward.

I want to thank you both, Dr. Anna Lee and Dr. Erin Gillespie, for sharing your valuable insights with us today and for your dedication to addressing gender equity issues and oncology.

Dr. Anna Lee: Thank you so much.

Dr. Erin Gillespie: Thanks so much.

Dr. Fumiko Chino: Thanks to our listeners for your time today. You'll find a link to the article discussed today in the transcript of this episode. If you value the insights that you hear on the ASCO Daily News podcast, please take a moment to rate, review, and subscribe, wherever you get your podcasts.

Disclaimer:

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.

Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

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Dr. Fumiko Chino

Dr. Anna Lee

Dr. Erin Gillespie

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Disclosures:

Dr. Fumiko Chino:

None disclosed.

Dr. Anna Lee:

None disclosed.

Dr. Erin Gillespie:

Other Relationship: eContour.org