Sexism in medicine

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Sexism is defined as the prejudice or discrimination against a sex, especially against women.[1][2][3] When applied to medicine, sexism can present itself in a variety of ways, both on the levels of clinician and patient. Female clinicians face discrimination verbally through derogatory and aggressive comments, many times based on their appearance. These women face difficulties in their work environment as a result of largely male dominated positions of power within the medical field and can be denied initial hire or promotions.[4][5] Female patients face discrimination through the denial of treatment as a result of not being taken seriously. The possibility of gender differences in experiences of pain has lead to a discrepancy in treating female patient's pain over that of a male patient.[6] Similarly, men in nursing are often subjected to stereotypic treatment, rather than sexism, as a result of being in a largely female dominated field. These stereotypes include patients assuming sexual orientation, job title, or not feeling comfortable with a male nurse.[7]

History[edit]

Sexism has had a long standing history within the medical industry. The earliest traces of sexism could be found within the disproportionate diagnosis of women with hysteria as early as 4000 years ago.[8]

Hysteria was earlier defined as excessive emotions. Within a medical setting, this hysteria translated to the over exaggeration of symptoms and ailments. Because traditional gender roles usually place women at a subordinate position compared to men, the medical industry, which is seen as powerful, has historically been dominated by men.[9] These gender roles may have also contributed to why pain associated with experiences unique to women, like childbirth and menstruation, were dismissed or mistreated. In 1948 some women volunteered to take part in an experiment designed to quantify pain in laboring women. During their labor, their hands were burned.[10]

In a 1979 observational study, 104 women and men gave responses to their health in 5 areas: “back pain, headaches, dizziness, chest pain, and fatigue. When receiving these complaints, it was seen that doctors gave extensive checkups to men more often than women with similar complaints, supporting that female patients tend to be taken less seriously than their male counterparts with regard to receiving medical illnesses.[11]

In 1990, the National Institutes of Health recognized the disparities in research of disease in men and when. At this time the Office of Research on Women’s Health was created. A large part of its purpose is to raise awareness of sex affects disease and treatments.[10][12] In 1991 and 1992 recognition that a 'glass ceiling' existed which prevented from female clinicians from being promoted.[13][14] In 1994 the FDA created an Office of Women’s Health by congressional mandate.[15]

Gender roles[edit]

According to a study done in 2003, it can be seen that the numbers of women in medicine have increased significantly. This trend continues into today. In the United States, there has actually been a “progressive decrease in male applicants to medicine and a substantial rise in female applicants.” Gender difference have been found in the motivations for applying to medical school. Studies suggest that “male applicants are more motivated by financial, prestige, scientific and technical issues, whereas female applicants stress more ‘person orientated’ humanistic and altruistic reasons.” Gender differences have also been found in “attitudes toward health promotion.” In addition, male and female clinicians are likely to use different styles of communication. Male doctors were found to be more likely to “speak in an authoritative manner, give direct commands to patients, interrupt more, are perceived as more imposing and presumptuous, spend less time with patients, make fewer positive statements and smile and nod less.” Some studies have found that female doctors “provide more intensive therapeutic milieu that could lead to more open exchange and comprehensive diagnosis and treatment.” In addition, females have been found to take more precautionary measures and give more tests than men are.[16]

There is also a connection between gender roles in the medical field and family pressures. A study was done to determine how doctors combine their working lives with having a normal family life. This study analyzes three different strategies used by men and women in order to cope with managing a normal family life and a work-heavy career. The three different types of strategies that men and women use are “career dominant, segregated, and accommodated.” When it comes to the career dominant strategy, about 15% of women and 3% of men adopt this strategy. This strategy “implies a continuous, full time career and a reduced family life- living single or divorced and childless as a consequence of the career.” The segregated strategy is composed of 55% of women and 85% of men, and it “implies a continuous, full time career with family roles organized so as to enable more time to be devoted to the career.” And lastly, the accommodating strategy is adopted by 30% of women and 12% of men. This strategy “implies that work involvement has been reduced in some way to allow more time for family roles.” As can be seen by these statistics, men are more likely than women to devote more time to their job as opposed to their family.[17]

Medical education[edit]

Women are underrepresented in leadership positions in academic medicine. Women and men begin their medical careers at similar rates but they do not advance at the same rate.[18] Studies indicate a systematic bias that has resulted in relatively fewer appointments to academic chairs.[19][12][20][21][22] Thirty-two percent of associate professors at medical schools are women, 32% of associate professors are women, 20% of full professors are women, 14% of department chairs are women, and 11% of deans of medical schools are women.[18]

A factor that impedes women's opportunities for advancement in academic medicine is a “stereotype-based cognitive bias.” There are two forms of this. The first type is related to clear personal beliefs about women, such as believing that women are less committed to their careers than men and believing that women are worse leaders than men. The second type is implicit bias, which is harder to see because the biases are harder to see, but they still influence one's judgment and actions towards women. Although implicit gender bias still plays a role, explicit bias in academic medicine has significantly decreased during the past half century in the United States as a result of Title IX getting passed. Implicit bias has had little to no improvement. Cultural stereotypes characterize women as “communal,” such as kind, dependent, and nurturing, but characterize women as lacking “agentric” traits, such as logical, independent, and strong, which are typically used as a male stereotype. These stereotypes make it difficult for women to achieve in the workforce, specifically in medicine, science, and in leadership. While men are associated with “agentic” traits and women are not, this can lead to women feeling that their work is less valued and they typically receive fewer nominations for opportunities that can advance their career. It has also been found that gender stereotypes play a role in socializing students towards their specialties. For example, women are more likely to go into communal specialties, including family medicine, pediatrics, and internal medicine, while men are more likely to go into surgery, research, and be the chair of a position. If women to go into specialties dominated by males, they typically have lower statuses. Residency is the first time the medical students, or new physicians, get to be in a leadership role. Men who are too communal can be accused of being “wimpy” or “soft” whereas women who are too agentic can be accused of being “bossy” or “domineering.”[18]

These stereotypes are due to the lack of gender awareness and role models. Female medical students have reported sexual harassment and discrimination. This is of concern because these obstacles affect "the professional identity formation and specialty choice." Personality differences exist between male and female surgical students. Fewer women choose to specialize in surgery. The lack of female role models may discourage some from choosing a surgical career.[23]

A study by the National Medical Foundation found that 60% of women have reported that gender has had an effect on their educational experience whereas only 25% of males have reported that gender has had an effect on their educational experience. Women said they felt as though they had to be twice as good to be treated equal to men. Additionally, 30.7% of women reported overcoming fear and failure whereas only 19.4% of males reported overcoming fear and failure in education.[24]

One response to bias against women academics has been to conduct training for faculty and students to recognize bias and change their habits.[18]

Female clinicians[edit]

Elizabeth Blackwell became the first woman to graduate from a Western medical school in 1849.[25] To raise awareness of the importance of women physicians, Physician Moms Group and Medelita founded February 3 as National Women Physicians Day in 2016.[26]

Female clinicians have experienced sexual assault.[27][28] 30% of female clinicians have reported instances in which they were the victim of sexual harassment.[29] Sexual harassment is common amongst younger clinicians when they come in contact with male clinicians in power who have more seniority over them.[29] Due to their sense of power over their coworkers and employees, they feel empowered to commit acts of sexual assault.[29] When victims of their abuse remain silent, they allow such acts to persist in medical workplaces.[29] In many cases, the women that come forward about being assaulted have a hard time finding jobs afterwards because they are considered “troublemakers” rather than victims.[30] This often makes it difficult for the victims to find other jobs in the medical field.[30] Human Relations also tends to protect their company and its employees they consider assets before protecting those who are their victims.[31] This discourages women from speaking up for fear that their jobs may be in jeopardy and that their claims will not be believed.[30][31] Future female employees then suffer the consequences of their silence because the cycle of misconduct continues to occur.[31]

In addition to falling victim to sexual assault in the workplace, female surgeons have also been found to fall victim to the wage gap.[32] Females were reported to have lower salaries than male surgeons.[32] In a study conducted in 1990, male clinicians were making a mean earnings of $155,400, while female clinicians were making a mean earnings of $109,900; about $45,500 less than their male counterparts.[32] As of 2016, female physicians have statistically been found to make about $18,677 less than male physicians.[33] Disparities between male and female surgeons has also been blamed upon not being as qualified as men to commit to leadership roles that earn them higher salaries.[33] Yet women are just as willing as men to accept positions of leadership when they are equally qualified. In many cases, women clinicians are equal to men at leadership tasks.[2] Other clinicians have expressed that they believe women in medicine are less committed to their careers and women are less effective as leaders.[18]

Moreover, female clinicians have also experienced barriers within finding the support to balance both working and having or maintaining a family. It has been reported that females are more likely to return to work after having a child part-time as opposed to full-time because they lack the support they receive by both their employers and society as a whole. It was found that the percentage of female clinicians working part-time in either a hospital setting or a general physician's office after having a child is much higher than the percentage of these women working full-time after having a child (92.7%, 96.3% 59.2%, 76.5% respectively).[34]

Furthermore, female physician narratives have described instances of sexism.[35] Female physicians are often mistaken for nurses by patients.[30] Patients have also been reported to have less trust in their physician if they are female and instead ask for a second opinion from a male physician.[30] Women physicians, on the other hand, have also been found to partake in sexist actions. Female clinicians often treat women patients differently than they do men.[36] Women physicians were found to admit less female patients to intensive care units because they were proactive in treating them in the emergency room, rendering their admittance to more intense care units unnecessary.[36]

Wage gap[edit]

Communal specialties, which women are more likely to go into, often have a lower pay than the specialties in which men typically go into. Women have been found to have a larger representation than men in lower-paying specialties, such as pediatrics and men lave a larger representation in higher-paying specialties, such as cardiology and surgery. In New York State between 1999 and 2008, the average starting salary for men was $187,385 whereas the mean starting salary for women was $158,727.[37] In 2001, it was found that male physicians earned roughly around 41% more than their female colleagues.[34] As of 2017, an updated version then found that the percentage had dropped to roughly around 27.7%.[38] That is roughly around a 100,000 dollar difference in salary per year. However, women who work in radiology are the only women who make more than their male colleagues—the difference is only about 2,000 dollars.[39] A study published in 2005 found that women physicians in the US had an annual earning gap of 11% if they were married, 14% if they had one child, and 22% if they had more than one child. Women typically had household obligations that affected their ability to work as much as men and therefore led to a trade-off of higher earnings for family-friendly jobs.[40]

Male clinicians[edit]

Men often decide to become nurses for self-actualization or survival needs, or simply because their original plans did not work out. However, there are a handful of men who decide to become nurses and start their studies with that goal in mind. Unfortunately, when men enter the field of nursing, they encounter many barriers that limit their choice of specialty. They run the risk of being labeled and stereotyped. These gender biases and role stereotyping occur because of the fact that nursing facilities are often composed mainly of women. Nursing tends to be identified with feminine style of care.[41]

Males only make up 9% of nurses. Stereotyping of men is related to nursing being considered a profession for women.[42] Men tend to face two common stereotypes when it comes to being nurses. The first being the stereotype that male nurses are gay since they are in a “feminine occupation.” The other common stereotype is that men are generally hypersexual and that this will inhibit them from being able to provide intimate care to women in nonsexual ways.[43]

Issues regarding sexism in/against male clinicians are harder to describe except possibly by example. Male nurses report:

  • being mistaken for a doctor
  • being asked to see the 'pretty' nurse
  • being called 'Doc' even when the patient knew the man was a nurse
  • being discounted as 'only' a nurse rather than a doctor by other professionals
  • being asked: "when are you going to become a doctor?"
  • being told that a female nurse is preferred[44]
  • being bullied on the job
  • being teased as a child for wanting to be a nurse[45]

Other questions are often asked of male nurses such as 'why did you go into nursing'? Or they are asked if they are gay, failed medical school, or became a nurse because it was easier. Sometimes a male nurse can be asked if he is nurse so that he can see undressed women.[44] In some instances male nurses were assumed to be the 'muscle' for other female nurses. Nursing supervisors tended to ask patients if it was alright to assign a male nurse to provide care. Male nurses have reported bias directed toward them during their studies. They experienced anxiety, insomnia, anger, and trepidation in anticipation of being treated poorly.[42]

Another difficulty that male nurses face is that they are passed over for work with female patients, or they are not allowed on birthing or gynecological units. This is concerning due to the fact that male doctors are completely welcome in these situations. In addition, male nurses find that they are pushed toward tasks that are stereotypically consistent with their gender role. Some of these might include heavy lifting, administrative roles, or psychiatric nursing.[46]

Female patients[edit]

Female patients are often treated differently from men. Women have been described in studies and in narratives as emotional and hysterical.[12] Historically, women's health has been called "bikini medicine", which is why clinical research specifically for women were limited to only focusing on breasts and reproductive organs. Aside from these research focuses, clinical research mainly used male subjects, but apply results to both genders. Because of this, some physicians assume that women should be assessed and receive identical treatments as men. Narratives include the reporting that women's complaints are considered exaggerated and may be assumed to be invalid.[47][48] Because of this women are often subsequently are referred to psychiatrists for treatment.[47] The tendency of treating pain in women with antidepressants exposes the women to developing side effects to medication that they might not even need.[49] The report of medical concerns by women are more likely to be discounted, misdiagnosed, ignored and assumed to be psychosomatic.[12][47][49][50] One observer has stated that, "different forms of female suffering are minimized, mocked, coaxed into silence."[48] There are those that disagree with this characterization.[51][10]

Clinicians are not as likely to assess women for substance abuse as often as they assess men. They also tend to miss signs of substance addiction in women. Women are not as likely as men to be assessed for alcohol abuse. Out of those women who are found to have an alcohol problem, they were found to be less likely to be referred for treatment. Those women in the childbearing years are prescribed more prescription medications than men. It is generally more common for women to be prescribed antipsychotics and opioids.[52] 

Women report feeling like they were 'silly' by male physicians but female physicians were more sensitive and preferred.[12] In a study of multiple men, women, and married couples, it was observed that men's complaints about physical health were evaluated more in depth than women's.[11]

Sex-selective abortion is the medical procedure or treatment that terminates a pregnancy when the baby is an undesired gender. The abortion of female fetuses is most common in areas where the culture values male children over females.[53] [54][55]

Sex selective abortion has been heavily utilized in numerous Asian countries. A British medical journal stated: "Compared with the normal ratio of about 95 girls being born per 100 boys (which is what we observe in Europe and North America), Singapore and Taiwan have 92, South Korea 88, and China a mere 86 girls born per 100 boys."[56]

When individuals encounter the medical field, many are in vulnerable states in their lives, whether that be because of illness, injury, death, etc. Both men and women experience this vulnerability, and must entrust their bodies and lives into the hands of practitioners. Men and women could still have varying outcomes and repercussions to mistreatment within this system. Specifically for women, there is a strong association between their physical form and their femininity. Mistreatment of a female’s body, may not only pose a threat to their life, but also their social acceptance. Medical industry seeks to fix “abnormalities” within the body, and in that way practitioners may be reinforcing stereotypes. In her book, The Cancer Journals, Audre Lorde speaks about her unpleasant experiences as a breast cancer patient and her struggle towards finding strength within after undergoing a mastectomy. Some women are given the option to use prosthesis, but Lorde highlights that this "treatment" aligns with the idea that perfection of the female body must be essential to the female identity.[57]

Clinical trials and research[edit]

Most clinical trials published before 1988 included no women and so many older medications on the market were never evaluated for their effects and side effects on women.[58][59] The physiology of male sex differentiation is described as "well studied, whereas the pathways that regulate female sexual differentiation remain incompletely defined".[60]

In the 1950s and 1960s "women's health' was mostly considered only as reproductive health, and women who were capable of bearing children were excluded from clinical trials to avoid any risk to a potential fetus.[61] Additionally, the thalidomide tragedy led the FDA to issue regulations in 1977 recommending that women should be excluded from participating in Phase I and Phase II studies in the US.[15] The approach to women shifted from paternalistic protection to access in the early 1980s as AIDS activists like ACT UP and women's groups challenged ways that drugs were developed. The NIH responded with policy changes in 1986, but a Government Accountability Office report in 1990 found that women were still being excluded from clinical research. That report, the appointment of Bernadine Healy as the first woman to lead the NIH, and the realization that important clinical trials had excluded women led to the creation of the Women's Health Initiative at the NIH and to the federal legislation, the 1993 National Institutes of Health Revitalization Act, which mandated that women and minorities be included in NIH-funded research.[61][62][58] The initial large studies on the use of low-dose aspirin to prevent heart attacks that were published in the 1970s and 1980s are often cited as examples of clinical trials that included only men, but from which people drew general conclusions that did not hold true for women.[58][63][64] In 1993 the FDA reversed its 1977 guidance, and included in the new guidance a statement that the former restriction was “rigid and paternalistic, leaving virtually no room for the exercise of judgment by responsible research subjects, physician investigators, and investigational review boards (IRBs)”.[15]

The National Academy of Medicine published a report called "Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies" in 1994[61] and another report in 2001 called "Exploring the Biological Contributions to Human Health: Does Sex Matter?” which each urged including women in clinical trials and running analyses on subpopulations by sex.[15][65]

A 2005 review by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use found that regulation in the US, Europe, and Japan required that clinical trials should reflect the population to whom an intervention will be given, and found that clinical trials that had been submitted to agencies were generally complying with those regulations.[66]

A review of NIH-funded studies (not necessarily submitted to regulatory agencies) published between 1995 and 2010 found that they had an "average enrollment of 37% (±6% standard deviation [SD]) women, at an increasing rate over the years. Only 28% of the publications either made some reference to sex/gender-specific results in the text or provided detailed results including sex/gender-specific estimates of effect or tests of interaction."[67]

The FDA published a study of the 30 sets of clinical trial data submitted after 2011, and found that for all of them, information by sex was available in public documents, and that almost all of them included subanalyses by sex.[15]

As of 2015, recruiting women to participate in clinical trials remained a challenge.[68]

In 2018 the US FDA released draft guidelines for inclusion of pregnant women in clinical trials.[69][70]

See also[edit]

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