Lifestyle, Opinion

Gender bias in healthcare: what still needs to be done

Introduction

I don’t normally do these types of chatty/opinion posts but I’m going to try to start doing more of them, so let me know how you find them!

Please note

In this post, when talking about gender bias, I am using the word gender as defined by one the papers I am referencing to be ‘embracing both the biological and social aspects of being male or female’. I understand that the concepts of gender and sex are not as simple as this, but I can only present the evidence as it is reported, it is not my intention to offend or exclude anybody to whom these terms don’t apply.

When looking at where we are today, compared to many years ago, we can see that we’ve come a long way in terms of gender equality, especially in the UK, but this doesn’t mean that the issue is completely solved. Gender bias is still present within healthcare, both on the staffing side and the patient side. I’m also going to talk a bit about gender blindness in research.


Doctors

According to Statista, as of 2019, there were about 162 thousand male registered doctors in the UK compared to 139 thousand female registered doctors. Of these 162 thousand male doctors, around 49 thousand were specialist doctors, which is nearly twice the number of female specialist doctors (28 thousand). One explanation for this is that generally women have to take off more time to have children and so it can take longer to get through speciality training. 

Motherhood is a big factor to consider for any woman chasing a successful career. For me, even though I am only 22, I know that being a mother one day is incredibly important to me, and I know that there will have to be sacrifices to be made.Whilst certain provisions can be made for women to return to work part time, there is no getting over the fact that women are the ones carrying the children, inevitably meaning that it is going to take longer for them to specialise. 

Many women might feel the pressure of going into typically ‘female specialities’ such as Paediatrics or General Practice. In fact, more GPs are women than men, which could be due to the more ‘family-friendly’ lifestyle that being a GP offers: a more regular schedule, no night shifts, relatively easy to go part time. But not every woman wants to become a GP.

Thankfully, according to the NHS Digital website, the proportion of women in every speciality is increasing, and in psychiatry, clinical oncology and dental, women have overtaken men (slightly), accounting for 51%, 53% and 51%, respectively. 

However, there is one area of medicine which is still heavily male dominated, and I bet you can guess which one.

Surgery

As of 2019, only 27% of surgeons are women. The proportion of women that make it to consultant surgeons is even lower. The Royal College of Surgeons states that as of 2020 just 13.2% of consultant surgeons are women. At least, there’s been an improvement since 1991, when this number was just 3%.

So why aren’t there as many women in surgery, and why are they not getting to the same level as men?

Obviously we have to consider the previous argument that women, should they choose to have children, have to take time out during training to carry and raise children.

In my final year of my undergraduate degree, I attended a talk by a surgeon on the topic of women of surgery. She asked each one of us directly what barriers we saw for a woman becoming a surgeon. As you might have guessed, the topic of motherhood came up. She showed us videos from her colleagues who were all surgeons, as well as wives and mothers. One of the common themes from all the videos was that they had, what they described as, ‘understanding’ husbands. It seems like a strange word to use, but basically these husbands had taken on the ‘typical’ role of the mother, they were the ones who were part time GPs, and used the rest of their time to take care of the children.

Another reason for this discrepancy is the fact that surgery is so associated with men, it may put off women for applying for surgical roles. A 2019 study of 131 surgeons in California found that they tended to associate men with surgery and women with family medicine, and that men were more likely to express this bias explicitly. 

When I was on work experience in surgery once, I asked the only female consultant surgeon that I met, ‘how does it feel to be a surgeon as a woman?’ which now seems like a really stupid question to ask. She responded by saying that she often wondered when we would get to the point where people didn’t ask questions like that anymore, when it would be so normal for women to be surgeons that questions like mine would seem strange. To be honest, I found that response even more useful and inspiring than if she had actually answered my question, because it made me also look forward to the day we get to that point.

Gender pay gap

According to the BMA, on average women hospital doctors earn 18.9% less than men, and women GPs earn 15.3% less than men. These are the adjusted figueres (women tend to work fewer contracted hours), and is thought to be influenced by the underrepresentation of women in higher paid positions and specialties. However, even when they adjusted for age and seniority, there was still a gap. 

The BMA acknowledges that medical careers tend to be structured around a male-dominated workforce, who can normally commit to working full time for pretty much their whole careers, as well as taking on extra responsibilities, but this isn’t the case for most women. More work needs to be done to support women returning to work from having children, and allowing more flexibility within speciality training. Men should also be encouraged to take more time off from work to care for the children, easing the burden on the mothers. 

A piece of positive news for female doctors is that they tend to be reported to the GMC a lot less than male doctors, obviously not as positive news for men… 


Nurses

Nursing is a heavily female-dominated profession, in fact, in 2017 it was reported that just 10.8% of nurses were men, making it one of the most gender segregated jobs in the UK. And unlike the increasing number of women in surgery, there doesn’t really seem to be a rising number of male nurses (0.1% increase since 2006). So whilst we need to be putting effort into getting more women into surgery, we should really be focusing on getting more men into nursing as well. 

One of the most obvious reasons for the lack of men in nursing is the stigma that’s associated with it. Men used to only be able to get nursing roles in mental health hospitals as they were thought to be more physically suited to deal with aggressive patients. Even though we’ve moved on from those times, there still seems to be a stigma about men being nurses. 

Another point to consider is the effect of language. For example, the head nurse on a ward is typically called a ‘sister’, which obviously isn’t really used for men, and so are called ‘charge nurse’ instead. If we are to make nursing a more accessible profession for men, surely we should be adapting to more gender-neutral language, in the same way as we have changed fireman to firefighter and policeman to police officer. 

It is worth noting that in nursing, there appears to be no gender pay gap when looking at hourly pay (there is a weekly gender pay gap but this is due to men typically working more hours).

PPE

With the current pandemic, the question of suitable PPE has once again been brought up. According to Nursing Standard, 77% of the NHS workforce is female, but only 3 in 10 women say the PPE they use was designed for the female frame. This may seem like a silly issue at first, but there are safety concerns. If a gown is too long, a woman may trip over it, if a mask is too big then it won’t be safe to use.


Health Outcomes

One of the guiding principles of the NHS is that it offers a service to ALL, but according to Caroline Criado Perez’s book ‘Invisible Women’ the medical education system does not prepare doctors to do this in the best way. The male body is often seen as the ‘default’ and the female body is taught based on how it differs from this norm. Traditionally this difference was thought of as being just reproductive organs and general size, but as research has progressed, we’ve found that this is obviously not the case. Even in aspects of medicine where sex-differences are well established, medical education doesn’t always pass this information on to the students. 

A paper published in 2008 found that for numerous conditions, Parkinson’s Disease, IBS, neck pain and more, men were investigated and treated more extensively than women with the same severity of symptoms. Doctors are also more likely to believe men’s symptoms as being organic, and women’s as psychosocial. However, this may be due to the tendency for women to describe their symptoms more vaguely than men.

For black women, the reality is even worse, in the UK, black women are 5 times more likely to die in childbirth than white women. In the US, the death rate of black women in childbirth is the same as for women in much lower-income countries such as Mexico and Uzbekistan. So whilst I am hoping for an improvement in healthcare for women in general, I am emphasising the desperate need for an improvement in particular for BAME women.


Research

One of the reasons for different health outcomes for men and women is due to the data available. A big issue for gender bias in healthcare is gender blindness in research. This is when research is either mostly, or exclusively, carried out on men, but the findings are applied to women as well. Even though guidelines have been introduced in places such as the USA to ensure women are included in trials, there are still recommendations being made based on this gender blind data. 

According to Invisible Women, even though ‘women represent 55% of HIV-positive adults in the developing world’ and it is known that they experience different clinical symptoms and complications, in a 2016 American review, women accounted for just 19.2% of antiretroviral studies, 38.1% of vaccination studies and 11.1% of studies trying to find a cure.

Why aren’t women included in clinical trials as much as men? 

  • Female bodies are too complex
  • Female bodies are too costly to be tested on
  • Integrating sex and gender into research is ‘burdensome’
  • Women should be excluded on the basis of ‘simplification’

These are all excuses that have been used.


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References

  • Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons Arghavan Salles, MD, PhD; Michael Awad, MD, PhD; Laurel Goldin, MA; Kelsey Krus, BS; Jin Vivian Lee, BA; Maria T. Schwabe, MPHS; Calvin K. Lai, PhD
  • Adebowale Victor, Rao Mala. It’s time to act on racism in the NHS BMJ 2020; 368 :m568
  • Hamberg K. Gender Bias in Medicine. Women’s Health. May 2008:237-243. doi:10.2217/17455057.4.3.237

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