Over the last few years, medical professional environments have seen a change with increasing workforce diversity due to immigration as well as exponential growth of women and minority populations among medical trainees. The positive impact of diversity is well recognized, and it is promising to see the evolving knowledge and research in this area (1–28) ¹ ; yet, many professionals continue to face discriminations related to gender, racial background, sexual orientation, or inequities in terms of access to leadership positions, compensation, or professional promotions. Active plans are thus needed by transplant stakeholders both at global and institutional scales to reduce discrimination and to promote female and minorities access to leadership positions. The current review focuses on the burden and impact of disparities and proposes potential solutions to mitigate these inequities.

According to a recent survey by the Equity, Diversity, and Inclusion (EDI) Committee of the International Liver Transplantation Society (ILTS), 35% of liver transplantation (LT) professionals reported a form of discrimination (1). The reasons for very low rates of woman leadership are consistent across the reports (2–5). A survey by the ILTS EDI Committee, which included 243 transplant centers globally, reported that only 32 (13.2%) had at least 1 woman as the director of LT, chief of transplant surgery, or chief of transplant hepatology (6) while another survey found that woman leadership was present in only 8% of 856 transplant programs globally (1) (Figure 1). Lowest woman leadership was in transplant surgery followed by hepatology and anesthesia (14.2% vs. 20% vs. 32.1% respectively, p = 0.046) (1). Disparities are also notable in the academic sphere, affecting the proportion of female professionals and minorities represented in senior authorship and transplant journals’ editorial boards (7, 8).

Female surgeons face obstacles, not only in leadership but also advancing their technical skills; as surgeons they are more commonly assigned as assistant surgeon as opposed to being primary surgeon for complex cases; consequently, they end-up having overall less case numbers within the same specialty or less cases for complex cases (9–11). They also face obstacles based on societal perceptions and not having supportive systems for an equitable career growth (9–11). In relation to these issues, the high incidence of attrition experienced by early-career abdominal transplant surgeons is concerning (12). Similarly, while there is wide variety in hepatology workflow and compensation, a burn out percent of 35% among trainees pursuing careers in transplant hepatology is alarming (13).

In reviewing the ILTS data, over the last 5 years (2017–2022), the female participation rate was 25%–31%, highest years being 2021 and 2022 at 31%. For the 2022 conference, although 21% did not specify their field, female participation was 45% in hepatology, 44% anesthesia and critical care followed by 20% rate in surgery. With the leadership and society efforts, female moderator and female speaker rates went up gradually and annually from 20% to 37% and 21% and 36%, respectively, between 2017–2022 (Figures 2, 3). Similarly, gender distribution of accepted abstracts reached 30% in the last year (Figure 4). Given 30% of total female attendance to the entire conference, speaker and moderator rates of 30% is a clear demonstration of the equitable representation of female participants in ILTS meetings which should be taken as a role model for all professional societies. Regarding country representation, six countries (USA, China, Republic of Korea, Turkey, United Kingdom, and India) accounted for between 50% and 57% of the total attendance in the previous 5 years (2017–2022), which may be reflecting limited access from underdeveloped countries to international medical conferences. Obviously, size of the country and total number of transplant programs would directly impact the participation to meetings. Regardless, attendance from Africa or the rest of the Asian continent remained low relative to North America and Europe. This is one of the areas ILTS and EDI committee is currently working on. For instance, in 2020, ILTS conducted an educational outreach initiative to help develop educational activities focused on the needs of specific regions around the world. The initiative is called the ILTS Regional Expansion of Advanced Learning (REAL) project. The aim of this initiative is to reach out to the different regions, mainly underdeveloped areas, where LT education is much needed, via educational programs tailored to what the key opinion leaders expressed (in prior surveys) as topics or areas of needed learning in their regions. REAL Asia was launched in 2020, REAL Latin America in 2021 and more recently REAL Africa 2022; representing a good example of the collaboration between the educational committee and EDI committee to maximize inclusiveness in educational initiatives.

Representation of women participants can be augmented both by encouraging more female professionals to participate in scientific events as well as encouraging the professional societies to be more inclusive of women in organizing committees and nominating them for moderator or chairperson roles and encouraging male professionals to recognize the achievements made by women in this challenging field. It is not a question of gender but a question of having the same unbiased opportunities within the given field.

With increased representation of younger members in the field (17), they seem to be integrating into medical societies by creating subgroups or specific subcommittees in the various specialties. This can provide a good opportunity for younger members to establish their footprint as well as gain leadership skills. This would also serve to rejuvenate professional societies with new creative ideas. On the other hand, there needs to have mentors at the society level who can understand the expectations and needs of these of young members (18). ILTS founded the Young Investigators (YIs) subcommittee bringing together a variety of specialties that have expertise and training background in LT.

Online surveys have proven to be a tool used and appreciated by younger age groups (19). Despite several limitations in health epidemiology, they remain a valuable instrument for exploring trends (20). The role of online resources has become prominent in recent years and YIs rely upon online clinical resources in their practice (21). Even the use of social media has become very popular in the field of liver disease (22). In this respect, ILTS offers a wide range of online resources for its affiliates, stratified by macro-areas of interest (anesthesia, surgery, hepatology). Specifically, ILTS has promoted the Vanguard Committee. This committee’s mission is to promote the participation of younger members of the LT community in all ILTS activities, and to guide the society in responding to their educational and professional needs. Scopes of the committee include: to organize the part of the annual congress dedicated to YIs; to select the best published clinical and basic science research papers during the calendar year for the Vanguard Awards; to contribute to the Scientific Content in the monthly ILTS Newsletter; to assist in social media profile management and to lead monthly ILTS Vanguard Webinars on complex cases in LT.

Significant disparities exist in the field of LT at multiple levels from leadership to training to societal representation. These disparities can have a remarkable impact on career development of the affected LT professionals. As ILTS and other international societies continue to provide initiatives, the support should be extended to local institutions aiming to mitigate inequities, strengthen the networking among underrepresented providers, and enhance optimal clinical practice, academic promotion, and leadership development in the field of LT.