Professional Documents
Culture Documents
OBJECTIVES The implementation of and consequence of the time and space it requires.
communication about matters associated with Gender-related issues were considered to be
gender in medical education have been unscientifically presented, to mostly concern
predominantly perceived as women’s issues. women’s issues and to tend to involve ‘male
This study aimed to explore attitudes towards bashing’ (i.e. gender issues were often labelled
and experiences of gender-related issues among as ideological and political). Interviewees
key male members of faculties of medicine. asked for facts and knowledge, but questioned
specific lessons and gender theory. Experiences
METHODS We conducted semi-structured of structural constraints, such as prejudice,
interviews with 20 male education leaders from hierarchies and homosociality, were presented,
the six medical schools in Sweden. The making gender education difficult and
interviews were analysed qualitatively using a downgrading it.
modified grounded theory approach.
CONCLUSIONS The results indicate that male
RESULTS The core category – ‘important… but faculty leaders embrace the importance of
of low status’ – reflects ambivalent attitudes gender-related issues, but do not necessarily
towards gender-related issues in medicine recognise or defend their impact on an area of
among male education leaders. All informants significant knowledge and competence in
were able to articulate why gender matters. As medicine. To change this and to engage more
doctors, they saw gender as a determinant of men in gender education, faculty measures are
health and, as bystanders, they had witnessed needed to counteract prejudice and to upgrade
inequalities and the wasting of women’s the time allocation, merits and status of gender
competence. However, they had doubts about implementation work. Based on our findings,
gender-related issues and found them to be we present and discuss possible ways to interest
overemphasised. Gender education was seen as more men and to improve gender education in
a threat to medical school curricula as a medicine.
Department of Public Health and Clinical Medicine, Family Correspondence: Gunilla Risberg, Department of Public Health and
Medicine, Umea University, Umea, Sweden Clinical Medicine, Family Medicine, Umea˚ University, Umea˚ SE
90185, Sweden. Tel: 00 46 907853557; Fax: 00 46 90776883;
E-mail: guarig97@student.umu.se
ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 613– 613
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G Risberg et al
25 26,27
gender among students, doctors,
INTRODUCTION 28,29 30,31
researchers and faculty members. Literature
published in the last few years shows that harassment
Gender has been recognised as a key determinant of
and discrimina- tion hurt not only the victims
social outcomes, including health and access to
themselves and their organisations, but also directly
health care. Gender also strongly influences career
male
affect and
the female colleagues
well-being of within the organisation. 32
opportunities. Consequently, knowledge and aware-
Gender bias, such as manifested in the neglect of
ness of gender-related issues are important among
1–4 women’s health issues and gender stereotyping, has
medical professionals.
also been shown in educational material and medical
textbooks33,34 and in medical curricula. 35,36
In medicine, the term ‘gender’ is often mistakenly
2,5–7
used as if it were synonymous with biological sex.
These insights have given rise to a discussion on how to
Yet gender is a wider concept than sex and refers to
prevent and avoid gender bias in medicine. One way
more than biological differences between women and
2,4,8,9 would be to introduce and implement a gender-based
men. Gender refers to the constant, ongoing perspective and gender-associated issues in medical
social construction of what is considered to be
education. 37,38 Here, teachers are key persons. Reports
‘feminine’ and ‘masculine’ (‘doing gender’), a con-
from such implementation efforts describe the hard
struction based on the asymmetrical distribution of
work required to inform and interest teachers. 3,39–42
power between and socio-cultural norms about
8–11 One obstacle is that gender issues seem to be consid-
women and men. Socio-cultural norms build on a ered to represent women’s issues. Studies carried out
dichotomous thinking about women and men, which
in the USA43 and Canada 44 showed that female
suggests the existence of innate and stable differ-
12 medical faculty staff were more gender-sensitive and
ences. The concept of gender, however, implies the found gender discrimination to be more of a
possibility of change and negotiation. We all ‘do problem than men did. A questionnaire study of
8–10
gender’ in all kinds of social interactions. In medical teachers in Sweden showed that women
professional everyday life, doctors, too, ‘do gender’. regarded gender as more important in professional
For example, when they ask female patients more did men 45 and that men had more dismissive
relations
than
13
than they ask male patients about their family, attitudes towards gender-related issues. 46 When
doctors are demonstrating that they are influenced gender was integrated into medical curricula at all
by, and contribute to maintaining, the gendered Dutch medical schools in a national project in
view that family matters are women’s issues. An 2002–2005, female teachers were more accepting of
alternative way of doing gender would be to challenge these changes than their male counterparts. 41 How-
this view by asking male patients about their family ever, to establish gender as an important field of
situation as often as female patients. knowledge among medical students, knowledgeable
and interested teachers of both sexes are needed.47
Thus, a gender-aware perspective in medicine implies
How do we encourage more male teachers to become
consideration of life conditions, positions in society
involved? To the best of our knowledge no study has
and societal expectations about ‘femininity’ and
investigated male teachers’ attitudes towards and ideas
‘masculinity’, along with biology in professional
about gender-related issues in medicine.
relationships, when theorising about women and
4,10,14
men. Unawareness of gender-related issues in
Consequently, the aim of this interview study was to
medical professionals can lead to gender bias in
focus on influential male teachers’ attitudes towards
medicine. Medical research has identified an abun-
15–17 and experiences of gender-related issues in medicine
dance of such bias in recent decades.
as a possible way of better understanding how to
interest more men in the subject and thereby
In clinical medicine, studies have shown that differ-
improve gender education in medicine.
ences that are not evidence-based occur in the
investigation and treatment of male and female
patients. Most research on this subject has been about
18 METHODS
coronary heart disease, but there are also studies
about many other conditions, including kidney Recruitment
19 20 21
disease, depression, colorectal cancer,
22 23
Parkinson’s disease, psoriasis, knee
24 13 We wanted to include male teachers who held key
osteoarthritis and neck pain. In academic
positions in medical education and had experiences
medicine, there are reports about discrimination and
harassment based on
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G Risberg et al
‘I get so upset when there are unjustified differences in Upset Bystander Gender is
income and things like that. It is just stupid. And that Injustice stress – witnessing important
women simply disappear as you go up the hierarchy Stupid of inequalities
ladder. I mean there is no difference in competence and Women disappear Waste of women’s
intelligence between women and men’ No differences in competence
competence or
intelligence
The study was approved by the ethics committee of mentioned a woman colleague as a source of inspira-
the faculty of medicine at our university. To secure tion. Two informants said that they had participated
anonymity, participants are not identified and no in short courses on the subject of gender, which had
connections between quotations and any specific made them more motivated.
person or university are indicated.
Being bystanders witnessing gender inequity in working
conditions for doctors, such as in salaries and career
RESULTS opportunities, was a common reason for becoming
engaged. Interviewees saw such inequity as a waste of
Table 3 summarises our analytical findings. The core women’s competence:
category – ‘important… but of low status’ – expresses
ambivalence towards gender and gender-related ‘I get so upset when there are unjustified differences
issues in medicine. It contains three categories that in income and things like that. It is just stupid. And
embrace the participants’ motives for considering that women simply disappear as you go up the
gender important (gender is important), their doubts hierarchy ladder! I mean, there is no difference in
about the subject of gender (…but not that important) competence and intelligence between women and
and the obstacles they had confronted when men.’
working with gender issues (…and not an easy task).
We present these categories and sub-categories. We Another reason was that students treat male and
use quotations from the interviews to illustrate female teachers differently:
the findings.
‘I lecture about gender together with a female
Gender is important colleague. We discuss the same issues, but the
students question her accounts and her credibility
All informants said that they thought issues of gender much more than mine.’
were important in medicine. They declared a variety
of incentives and sources for their interest in gender Students’ demands and actions were described as
issues. One overall motive was that gender is an important driving forces:
important determinant of ill health:
‘A group of our students has published a bunch of
‘We need to take gender into consideration to examples of gender-offensive remarks they have
succeed better with prevention as well as with cure.’ heard in class from their teachers. That list has been
a real eye-opener – it is a remarkable language
More specific causes of motivation ranged from we use.’
private experiences to seeing the implementation of
gender-associated policies as a faculty duty. Quite In Sweden, the government has decreed that a
often, informants ascribed their interest in gender- gender-related perspective should be implemented in
50
related issues to the women in their own families and two medical schools. The government has also initiated
interviewees specifically mentioned ideas passed on appraisals about gender in medical schools carried
to them from feminist daughters. One informant out by the National Agency for Higher Education and
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G Risberg et al
differences between women and men, rather than bution of power and that gender equity might imply
about the problematising of diversity, and were that men lose power and position:
critical of this:
‘If you see it like this, there is one dominant and one
‘Sometimes gender is overemphasised, because there subordinate group and of course the dominant group
is is seldom interested in surrendering power and
a large variation between individuals within the group privileges.’
of men and within the group of women. It’s probably
larger than the variation between the two groups.’ However, when power-related aspects of gender were
Several interviewees talked about gender mainly as touched upon, gender was often associated with
belonging to women’s territory, criticised the focus on feminism, which some informants described as intim-
women’s problems and opined that today men have idating and male bashing:
nothing to gain from gender-related discussions:
‘Feminism is a movement that has gone too far, and
‘You could easily get the impression that the inter- has become threatening and hostile to many men.’
pretations in gender research focus on negative
effects for women only. It would be wise to broaden They described female colleagues working with gen-
the analysis, to make it more generally applicable, der and gender researchers in a negative light, as
and show that there are negative effects for men as disappointed feminists, directed by ideology and
well. That might be a way to get more men bitterness rather than by scientific curiosity:
interested.’
‘Several feminists and gender researchers seem to
Other informants considered it self-evident that belong to a special category of people who are
women are more engaged than men because women dissatisfied with their situation and blame everything
belong to the subordinate group in the gender on their gender. They give many men an excuse to
hierarchy. One interviewee saw class and gender as hold on to their prejudices and to continue their
parallel cases in this respect: chauvinist attitudes.’
‘After all, it was the employees who started labour One participant, commenting on male bashing and on
unions, not the employers.’ how men can feel abused in discussions about gender,
proposed a constructive approach and concluded:
Several informants conveyed that equality endeavours
too could be exaggerated and distrusted and ques- ‘Don’t blame the men; blame the idea of gender roles
tioned the definition of concepts like inequity and that both men and women embrace.’
discrimination:
…and not an easy task
‘You know, some women students are very militant.
They notice if a supervisor says something clumsy and Most participants described not only their own doubts,
put it on the noticeboard. I mean [for example], if a but also how they had encountered scepticism or
supervisor says, ‘‘The blondes follow that doctor and indifference to the subject of gender from other
the brunettes come with me.’’ That is not inequity or colleagues. They also described structural constraints.
harassment; that is clumsiness.’ These were factors that had obstructed their work with
gender-related issues. They considered insufficient
Interviewees said they had perceived overtones, knowledge about gender to be a major problem, both
categorical solutions and emotions instead of facts among colleagues and in medicine as a whole. For
and thus were worried about unscientific teaching example, they noted a lack of awareness of subtle
approaches: inequities, such as how men and women are differently
treated in conference rooms and in examinations.
‘Positivistic research; that is what convinces us. We
can understand other things too, but it never has the Prejudiced attitudes were also described as a major
same deep impact. We must keep the scientific obstacle:
banner flying.’
‘It’s about attitudes, you know, and that is difficult.
Most informants acknowledged that gender- There are too many prejudices from all parties,
associated issues include some related to the distri- including myself.’
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G Risberg et al
of the interviewer was that most of the men talked However, the male teachers also described why
willingly and fluently, and that the data were enriched gender was not that important. A recurring theme
by the many personal experiences described. was their lack of time as teachers, but they also cited
lack of time and space for gender-related lessons in
One man abstained from participation because he curricula. Few informants had themselves prioritised
knew the researchers. Others may have recognised attendance at courses or lectures on gender-related
the researchers by name as gender researchers, which issues. One reason for considering specific lessons as
may have led them to try to express themselves in unnecessary was the belief that gender-related issues
politically correct ways. This we do not know. were self-evident and would emerge naturally. This
However, arguments both for and against the imple- is in line with reports from an Australian medical
mentation of a gender-related perspective appeared school at which the clinical teaching faculty staff
in the full data. believed that gender-related issues did not require
specific teaching time because they considered that
Findings in qualitative research do not represent appropriate attitudes would be learned by students in
proof, but, rather, consist of descriptions and the process of observing teachers’ interactions at
40
interpretations. Our method for selecting the bedside. Such a belief disregards gender as an
participants and holding interviews with 20 teachers area of competence and knowledge and may con-
in key positions at Swedish medical schools has tribute to its low status. We would never claim that
limitations. We cannot lay claim to representativity students will absorb cardiology simply by being near
and generalisability, but, rather, we aim to make our and observing cardiologists.
results recognisable and transferable to other
53
contexts. That all three researchers worked to- Another hindrance was that gender-related issues
gether on the analysis represents a strength of this were seen as being overemphasised by, for instance, a
study. Analyses were discussed jointly and perceived failure to take diversity into account.
disagreements were subjected to scrutiny in order to Modern gender theory, however, does indeed
54
obtain trustworthiness. emphasise diversity within groups of men and
55
women and stresses the fact that other hierarchical
On findings systems intersect with gender in relation to the
56
opportunities and positions available to individuals.
Our key faculty leaders were able to justify why Spokespersons for a gender-based perspective in
gender matters and to describe sources of inspiration medicine should remember that focusing almost
for the implementation of material on gender-based exclusively on biological and behavioural differences
perspectives. This is important information on which when communicating about gender implies an overly
to build. For instance, developing men’s interest in narrow focus that might restrain male as well as
knowledge of gender as a determinant of ill health female doctors from engaging in gender issues.
might expand the relevance of gender for both
women and men. Research of this kind, such as on Criticisms also concerned the communication styles
how men may be under-diagnosed and women used by female colleagues in gender research and
over-diagnosed with depression, has recently been education. Descriptions of these women as disap-
20
presented. pointed feminists who use overtones and emotions
rather than facts very definitely place them outside
The bystander stress experienced by men as they the scientific medical field. Given the enormity of the
watch the wasting of women’s competence or as they work carried out by many women pioneers during
witness the downgrading or harassment of women the last few decades to introduce gender-associated
is also recognised as a gender-related issue for men issues in medicine into curricula at Swedish medical
and may serve as a basis from which to build alliances schools, such harsh comments came as a surprise to
40,41,43
between women and men. us. Obviously, the way gender-related issues are
discussed can cause irritation. The project leaders
Our finding that students’ actions and demands were of a Dutch programme designed to mainstream
greatly influential in putting gender onto the agendas gender-related issues were urged to communicate
42
of faculty leaders is important. Students may think carefully to avoid resistance. However, focusing on
that their engagement has little impact on the way form more substantially than on content is a way of
curricula are planned. In this study, students’ actions disregarding and downgrading an issue. There is also
stood out as representing important eye-openers to a risk that unconscious techniques of suppressing
57
faculty staff. indiviudals, such as by blaming individual women or
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G Risberg et al
biologist Fausto-Sterling has argued that the way tend not to be diagnosed properly. Citing such
someone teaches science depends on how that examples may demonstrate that men do have
person thinks about the nature of scientific knowl- something to gain from supporting a gender-based
edge. She emphasises that, in today’s world, teachers perspective.
must place the scientific matter in a social context in
order to make use of their knowledge. This means Resistance to the power-associated aspects of gender
that a teacher does not lose the scientific essentials of can seem hard to tackle. We find that the comment
the course content if some traditional details are left made by one interviewee – ‘Don’t blame the men;
out to make space for expanded coverage because blame the idea of gender roles that both men and
the value of what students learn does not lie in a women embrace’ – is illuminating and summarises
61
specific set of facts, but in a way of thinking. most of our discussion. It illustrates the thin line
Accordingly, we argue that educators should not negotiated by communicators on gender and
worry that teaching about gender-associated issues described by Verdonk et al. as the line between being
will take time away from teaching about ‘basic considered confident and determined, which is
medicine’; what matters is that we teach about how to rewarded, and being judged as assertive (‘too pushy’),
42
interpret and understand different aspects of health which causes resistance. Even if gender educators
and disease. try to focus on the gender-based system – with its
gendered roles and asymmetry of power – as a system
To improve gender education, both men and upheld and reproduced by both women and men,
women must be involved. A few informants in our individual men may, and do, feel blamed and
study had noticed that male teachers were taken perceive the power-related aspects of gender as
more seriously than female teachers when teaching belonging to the realm of politics and ideology. To
about gender. Accordingly, bringing more male channel this frustration into dialogue and reflection,
teachers into gender education in medicine might it is important to arrange faculty education pro-
improve the status of the gender-based perspective. grammes on gender and also to discuss the risk of
Earlier research has shown that mainstreaming and male bashing in order to find ways of avoiding it. One
implementing a gender-based perspective in approach in such a programme would be to intro-
medicine is facilitated by alliances between duce theoretical knowledge and facts about structural
persons (women) aiming for change and senior gender patterns. Changing the focus from an indi-
male faculty leadership.
39,40,42
There is, however, vidual to a structural level may make the power-
an inherent dilemma in this strategy: improving related aspects of the subject of gender seem less
the status of gender education by involving more intimidating. Another approach would involve
men in it may endorse the asymmetry of the making space for reflection on one’s own doubts
respective status of men and women. The solution and motivation.
replicates the problem. Nevertheless, involving more
men in gender education is also a way of showing in
practice that gender concerns both men and Contributors: all three authors conceived and designed the
women. research and undertook the analysis and interpretation of
data. GR carried out the interviews and drafted the article.
Several of the male faculty leaders perceived gen- EJ and KH conducted the critical revision of the article. All
three authors read and approved the final manuscript.
der-related issues as mainly women’s issues. This
indicates that gender education ought to be Acknowledgements: none.
broadened. Gender-associated issues and gender- Funding: none.
influenced relationships have impact on men as Conflicts of interest: none.
well as on women and it is important to discuss this Ethical approval: the Ethics Committee of the Faculty of
Medicine, Umea˚ University approved the study (ref. 05-
in medical education. The norms of masculinity,
037 O¨ ).
like those of femininity, imply restrictions and
entail specific consequences, challenges and
difficulties. For example, there has been some
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