Embracing diversity in dermatology: Creation of a culture of inclusion in dermatologic publishing

Diversity in publishing is, in and of itself, a diverse concept. To be truly inclusive and embrace diversity in our dermatologic literature, it is critical that the chief editors and the editorial board of the journal examine how they are actively creating a culture of inclusion within and for their publication. Indeed, the concept of diversity includes issues regarding gender, race, and transgender/ gender minority/sexual minority issues and extends beyond the medical content of what is published within the journal. With regard to the International Journal of Women’s Dermatology (IJWD), we have taken an all-encompassing look at how to champion diversity and inclusion in our publication. Gender and racial diversity are not only limited to issues specific to women’s health or care of patients with skin of color, but also include diversity in authorship as well as our editorial team, and the professional development of our female and male dermatology colleagues of different transgender/gender minority/sexual minority backgrounds. We have embraced diversity in our authorship, diversity in our colleagues, diversity in the literature, and diversity in our patients and the issues that they face regarding their dermatologic health, creating a model that can be emulated in journals throughout different fields of medicine.

Diversity in publishing is, in and of itself, a diverse concept. To be truly inclusive and embrace diversity in our dermatologic literature, it is critical that the chief editors and the editorial board of the journal examine how they are actively creating a culture of inclusion within and for their publication. Indeed, the concept of diversity includes issues regarding gender, race, and transgender/ gender minority/sexual minority issues and extends beyond the medical content of what is published within the journal. With regard to the International Journal of Women's Dermatology (IJWD), we have taken an all-encompassing look at how to champion diversity and inclusion in our publication. Gender and racial diversity are not only limited to issues specific to women's health or care of patients with skin of color, but also include diversity in authorship as well as our editorial team, and the professional development of our female and male dermatology colleagues of different transgender/gender minority/sexual minority backgrounds. We have embraced diversity in our authorship, diversity in our colleagues, diversity in the literature, and diversity in our patients and the issues that they face regarding their dermatologic health, creating a model that can be emulated in journals throughout different fields of medicine.

Diversity in our editorial and advisory boards
The editorial board of the IJWD consists of two co-editors in chief, one deputy editor, and 32 associate editors. In terms of female representation on our editorial board, we have a higher percentage of female associate editors compared with the editorial boards of all other dermatology journals. In their article, "Representation of Women as Editors in Dermatology Journals: A Comprehensive Review," Lobl et al. (2019) demonstrated that women make up 18% of editors in chief and 22% of editorial board members. This built on previously published work in our journal regarding the low percentage of female editors-in-chief of dermatology journals . This is in stark contrast to the editorial board of the IJWD, in which both of our editors-in-chief are female, 83% of our editorial board is female (29 of 35 members), and 86% of our advisory board is female (12 of 14 members).
In terms of international presence, we have 11 editors from countries outside of the United States (31% of the editorial board), including Argentina, Australia, Denmark, France, Germany, Greece, India, Iran, and Switzerland. On our advisory board, 4 of 14 members are from countries outside of the United States (29% of the advisory board), including Brazil, Germany, Israel, and the Philippines. In terms of ethnicity, we have 24 editors of Caucasian descent (67% of the editorial board), 2 editors of Black descent (6%), 2 editors of Middle Eastern descent (6%), 2 editors of Latin American descent (6%), and 5 editors of East Asian descent (14%). Finally, our advisory board also has physicians specializing in internal medicine, obstetrics and gynecology, psychiatry, and ophthalmology, providing input from within the house of medicine and guide the development of the journal so that our publications are germane to physicians within various fields of medicine who care for patients in conjunction with our dermatology colleagues.

Authorship
As editors, we appreciate the importance of including first names in medical journals and congress publishing as a tool for assessing gender diversity in the medical literature. For many years, medicine was the prerogative of men, and physicians used titles and surnames to address each other more formally. Articles were published using surnames and initials, which makes it difficult to ascertain academic output of women. It becomes almost impossible to assess whether journals and congresses are providing sufficient opportunities for women without the use of full names. Another reason to include full names is the number of similar names in countries where there are limited surnames, such as China or Korea. Since its inception in 2015, the IJWD has been including the first names of authors to highlight the contribution of women to the articles we publish. Table 1 outlines the number of articles published per issue and the percentage of articles published with at least one female author. The impact of the IJWD on female professional colleague development is apparent in that we have published a total of 544 peer-reviewed articles to date, and an impressive 96% (522 articles) have at least one female author.

Personal and professional development of female colleagues
A key initiative of both the Women's Dermatologic Society (WDS), as well as the IJWD, is to support professional female dermatologists through mentorship, leadership opportunities, and guidance regarding personal and professional development. In January 2020, Dr. Michi Shinohara, a special-issue editor for the IJWD,  1  14  14  100  1  2  12  12  100  1  3  10  10  100  1  4  11  10  91  2016  2  1  10  10  100  2  2  10  10  100  2  3  9  6  67  2  4  10  9  90  2017  3  1  29  27  93  3  2  10  10  100  3  3  16  14  88  3  4  12  12  developed a gender gap special issue modeled after her course for the American Academy of Dermatology . A total of 61 articles from this special issue and over the lifetime of the journal (listed in Table 2 ) provide examples of publications elicited by the IJWD editors to promote female colleagues' personal and professional development. To further this initiative, both founding co-editors in chief and current co-editors in chief, Drs. Jane Grant-Kels, Dedee Murrell, and Jenny Murase, assessed the impact of gender on mentee-mentor success through the WDS Mentorship Survey, which is now published in this September 2021 issue .

Personal and professional development of colleagues with skin of color
The WDS and the IJWD value diversity and inclusion in our field. To this end, we have published an array of articles specific to fostering the personal and professional development of our colleagues with skin of color within dermatology. In this September 2021 issue of the IJWD, Desai et al. (2021) discuss what it means to create a culture of equity and inclusion in dermatologic societies, mirroring our description of how to create a culture of inclusion within dermatologic publishing. The American Academy of Dermatology, WDS, American Society for Dermatologic Surgery, Association for Professors in Dermatology, American Society of Dermatopathology, American Contact Dermatitis Society, and Skin of Color Society have all taken initiatives to address the inequities in our field. It is also encouraging to see how much the twin pandemic of racism has had a positive impact on diversifying our field the past two years Feaster and McMichael, 2021 ;Lester and Taylor, 2021 ;Sekyere et al., 2021 ). Table 3 outlines 14 articles we elicited in support of the personal and professional development of our colleagues with skin of color within dermatology.

Skin of color and diversity and inclusion in our literature
As co-editors in chief, we have embarked on initiatives to both increase the skin-of-color content of our publication and create a baseline metric for how dermatology journal skin-of-color content can be tracked over time. These two strategic initiatives were performed with the intention of promoting a culture of inclusion within our publication. The March 2021 issue of the IJWD featured 24 invited publications written on topics ranging from diversity within dermatology, allyship and advocacy, and diseases directly related to pigmentation and high hair curl type prevalent in skinof-color populations . In this September 2021 issue, we feature a study in which we developed a two-tier criterion to assess skin-of-color content for 52 dermatologic publications and ranked each of the dermatologic publications by their skin-of-color content, analyzing the most common categorizations and differences based on Scopus score, international versus noninternational, and scientific versus clinical publications ( Wilson et al., 2021a ;2021b ). These initiatives sent a clear message to our authorship, our readership, and our editorial board that we are interested in publishing articles on skin of color and diversity issues (52 articles are provided as examples in Table 4 ), which further helps to build a culture of inclusion, both within the editorial board and for the public facing aspects of our journal.

Gender minority and transgender diversity in our literature
The focus of the IJWD is on the dermatologic health of women and their families. This range of topics includes but is not limited to the role of hormones in the development of acne and alopecia; the skin manifestation of metabolic syndrome and polycystic ovarian syndrome; skin cancer risk specific to women; clinical considerations when managing chronic dermatologic conditions (e.g., atopic dermatitis, psoriasis, and cutaneous lupus in women); Table 2 Articles published in support of the personal and professional development of our female colleagues within dermatology the safety profile of dermatologic medical and cosmetic therapy in pregnant and breastfeeding women; the impact of esthetic procedures on body image and body dysmorphic disorders; chemotherapeutic concerns in dermatologic skin care in women with cancer; skin disease specific to women who are aging in menopause, pregnant, or breastfeeding; skin disease of the vulva and vaginal area; vaginal rejuvenation; and ethical issues when caring for dermatologic issues of women and their families. But importantly it also includes issues for our colleagues and patients with issues regarding gender minority and transgender dermatology, as well as gender minority and sexual orientation bias in the workplace. We have published articles related to transgender and gender minority patients ( Table 5 ), and this area in particular is one that we wish to focus our attention on moving forward and to purposefully recruit articles to further our strategic initiative as we strive to develop a culture of inclusion in dermatologic publishing.

Creation of culture of inclusion in dermatologic publishing
Ultimately, we believe editors, editorial boards, and publishers should be encouraged to critically examine diversity in their publications, including an annual assessment with metrics indicating how effectively a culture of inclusion has been fostered. Currently, journal success is evaluated through bibliometric milestones, such as Scopus scores, number of submissions and citations, and impact factors, but the culture of inclusion that the journal has built should also be factored into an evaluation of a journal's impact on its subspecialty and the importance of that journal in the field of medicine and within society.
We encourage evaluation metrics that 1) Examine editorial board and advisory board make up, including race, gender, ethnic background, and country of origin, the latter particularly pertaining to international journals. 2) Examine how the publication supports professionals from different backgrounds. 3) Examine the gender, race, and ethnic background of its authorship. 4) Examine topics published to foster knowledge of gender differences, skin of color content, sexual minority, gender minority and transgender issues, when appropriate.
It is ultimately the development of a culture of inclusion, a strategic initiative that is purposefully and thoughtfully executed by editors and editorial board members, that brings change to our society. Editors have a great responsibility in deciding what information is disseminated to medical professionals and the public in Table 3 Articles published in support of the personal and professional development of our skin of color colleagues within dermatology a peer-reviewed platform, where potentially more weight is placed on the validity of the findings published due to the rigorous review process for the published articles. It is easy to state that the inequity in our literature is not being addressed by the stream of articles submitted to the journal, but what if, as editors, we take the initiative to invite publications that directly address this inequity in our literature? Or to encourage research that would address these inequities? Or to welcome voices that would otherwise be unheard? The best counter action to discrimination against populations that have been marginalized in the past is to be intentional in preventing that discrimination from continuing. The onus is on us as journal editors to create a welcoming and inclusive environment that embraces our differences and is enriched by the knowledge and insight that results when these differences are identified, classified, analyzed, and studied. Diversity is important, but the development of a culture of inclusion on our editorial boards, in our authorship, and within our publication is the key to unlocking new material that benefits both the majority and the minority, the male and the female, the mainstream and the marginalized. Encouraging the voices of the marginalized is the essence of what allows for the creation of this culture. Therefore, fostering a culture of inclusion is vital to gaining access to the benefits of diversity. Let the marginalized of the past be heard for all of us to reap the benefits of inclusion.

Conflicts of interest
Dr Dedee Murrell identifies as female. She has served as founding co-editor in chief of the IJWD since 2014 and is the author of some of the cited articles. Dr Jenny Murase identifies as female. She has served as co-editor in chief of IJWD since early 2018 and is the author of some of the cited articles.

Funding
None.