International Women’s Day – How do we achieve gender balance in healthcare?

Laure-Anais Zultak and Hayley Blackburn

The theme for this year’s International Women’s Day is #BalanceforBetter and so we wanted to think about what this would mean for healthcare.

The impact of gender in health professions

More than half of medical students are now female and 2017 saw eight out of 24 Royal Colleges being led by women, including, for the first time, the Royal College of Surgeons.  Women have always been part of medicine – the Royal College of Physicians recently held an exhibition on the 500 years of women in medicine – but they are now an increasing proportion of the workforce.  This has not been without challenges.  For example a number of female doctors and nurses have talked publicly about the sexual harassment they have faced at work, and the Government is running its own review of the NHS gender pay gap.

Does gender affect patients and their care?

For many women across the world just accessing health services at all is a challenge, but even in countries where access to health services is easier for women, there is growing discussion on the impact of gender on healthcare.  For example, there is an increasing awareness about the impact of the absence of women from clinical trials.  This is particularly the case at early stages as women have been found to represent only 22 per cent of phase I clinical trial participants.  Historically, there may have been good reason for this, in light of safety considerations following thalidomide, but this does not explain why the resulting unintended disparity persists today.

There is also growing evidence on differences in the way men and women are treated.  Women may experience different symptoms for some conditions, for example back pain rather than chest pain as a symptom of heart failure.  Women are less likely to receive pain relief than men and to have their symptoms attributed to emotional or psychological factors, even when there are also test results to support what they are reporting.  These are examples which bear out the theory of ‘Yentl syndrome’ which suggests that women are less likely to be treated aggressively on their first contact with healthcare until they have ‘proven that they are as sick as male patients’.

At the same time, men are more likely to commit suicide than women, the reasons for this are complex and still poorly understood, but men are generally less likely to present at primary healthcare services which may indicate they also fail to access services such as mental health care.

What about how we communicate?

As communicators, this got us thinking about how gender affects various elements of our work.  How should it affect our communications with female, male and transgender health professionals?  Will patients of different genders respond differently to how information is presented?  Will a patient’s gender affect how they think about their condition or how their health professionals make decisions about their treatment?  How do we design communication campaigns that resonate with increasingly mixed audiences?

To explore this further for International Women’s Day, we have interviewed two women, Professor Jane Dacre, former President of the Royal College of Physicians, and Elizabeth Eves, oncology nurse, about their views on the impact of gender on health care, both for patients and for health professionals.  The full interviews are below, but some of the key issues they highlighted were:

  • The stereotyping of women and the specialities and roles they choose
  • The assumptions that patients make about the role of female doctors
  • The impact of gender stereotyping on professionals’ confidence
  • How gender can affect how people access care and support
  • How gender can affect how patients receive and engage with health-related information

We know that people respond better to messages from people who they identify with, that is people who look like them, and so we need to think about who our messengers are.  Recognising that our audience is not one group of people but a diverse range of people affected by a number of individual and environmental factors, including their gender, will help us to tailor messages and the tools we use to reach people.  We think gender is important to make perfect sense of health and will be doing more on this in the coming months.

Professor Dame Jane Dacre

Former President of the Royal College of Physicians

How much do you think gender and gender stereotyping affects health behaviours, care and outcomes?

I think it has done so throughout history and it still does fairly significantly.  My main interest in gender in health services has been in relation to female doctors in the workforce. There has been a lot of negative gender stereotyping that I see in relation to women and what careers they go into.  Historically as well there is a lot of gender stereotyping of women and how women behave with their care.  Just the overlap between the word hysterectomy and hysteria is interesting, that women are perceived to manage in themselves in a different way from men.

How much do you think language that patients and professionals use is linked to that gender stereotyping and its effect on patient care and professional developments?

I would like to think that people are professional enough in the language they use about female doctors not to affect the way that we care for patients.  But it sometimes demonstrates a lack of understanding of what women’s roles are in medicine.  Certainly, as a female doctor you are often mistaken for the most junior person in the room and you are quite often mistakenly called nurse because that is a traditional stereotypical role for women.  When I was quite a young doctor, although I was often in charge of the medical team, I was very often not spoken to by the patient who would assume that I was the nurse and that there was a male doctor.

That was an unfortunate stereotype, which I think undermined my relationship with my patients.  It did sometimes affect my confidence and my ability to be the doctor and to be making decisions about people’s care.

Do you think we should be paying more or less attention to gender in healthcare? Do we need to be thinking differently about men’s and women’s health or should we actually try to be gender-neutral?

That is a complicated question because there is evidence that some conditions are more prevalent in one gender or another so you can’t take gender out of health completely. When it comes to the way that you treat your patients as a professional, then one ought to be equally professional and respectful to either gender. But because stereotypes exist and because as a doctor your aim is to support your patients, sometimes you have to put up with some attitudes that come from patients that you wouldn’t put up with from your friends or your family.  Because you are demonstrating respect, you’re deferring your needs and to what is in the patient’s best interest.

The theme for this year’s International Women’s Day is #BalanceforBetter.  What do you think this means for healthcare?

It means that there should be equality of opportunity for men and women working in healthcare and that there also should be equality in access to treatment for people who are being managed by the NHS.  I think at the moment the world isn’t equal but it is a great aspiration to be equal.

One of the things that I am increasingly aware of because I am leading the Government’s [NHS] pay gap review is that even in different specialities men and women are treated differently and men and women choose to go into different specialties. And because the relative kudos associated with different specialities is variable, it means that doctors are not always equally respected for the work that they do.  I think that this needs to change.  And one of the ways to change that is to stop there being differential pay for men and women for doing a similar career.

Elizabeth Eves

Oncology Nurse, London School of Hygiene and Tropical Medicine student

How much do you think gender and gender stereotyping affect health behaviours, care and outcomes, and health research?

Thinking back to my clinical experience, I think gender has an impact on the amount and type of psychosocial support that patients seek during a cancer experience.  Primarily, men are less likely to access psychosocial support in cancer care.

Particularly, thinking about my work on a website, which provides written information for patients and families affected by cancer, we find that the majority of our users are female.  But when we have done more in-depth analytics, we have found that it is quite often female relatives that are looking for information to support a man that is affected by cancer.  It is often as if men are getting cancer support by proxy through a female relative, rather than accessing information themselves.

We have tried to approach the same subject, ie how to cope with the emotional aspects of cancer, using different language which we think would be more comfortable for male patients.  We have done testing around that and we have found that language does have a big impact on how males use cancer-related written information, and very often they won’t at all.

Going back to how gender stereotypes might affect health behaviours, I think men sometimes feel like it is a weakness to ask for, to seek, or to need psychosocial support when they are facing illness, not just cancer but any acute or chronic illness.  I think they can feel quite self-conscious about asking for that, and quite often will prefer information to be quite direct, and that they can take away and read at a later point. I don’t think that they find conversations with health professionals very easy from my experience.

That is perhaps reinforced by some of the gender dynamics within the workforce, because quite often it is a female nurse speaking to a male patient.  That brings in a lot of gender play there, particularly if it is an older male patient and a younger female nurse.  Age and gender can come together to make a patient even less able to ask some of the questions that they might have, particularly if it is around a sensitive issue.  For instance, if a male patient has prostate cancer and is concerned about incontinence or sexual dysfunction, they would find it absolutely mortifying to speak to young female nurse.  I know patients who feel like they won’t be as well respected by health professionals if they talk about sensitive issues and that is very difficult for people.  Gender comes into it quite a lot there.

Thinking about the career path of healthcare professionals, gender is a huge issue and language is very important in that.  I heard a speech a couple of months ago by somebody who is quite eminent in the nursing profession who spoke about nurses having very little confidence to lead.  I felt quite jarred by that because I think that part of nursing training and education, backed up by social rhetoric, almost socialises nurses into thinking that they don’t have confidence, and somehow implies that we shouldn’t have the confidence to lead. And unfortunately, some nurses start to believe that. It can have a long-term effect on nurses’ confidence.

I think that some styles of leadership, within the NHS for instance, can be looked at to try and think of techniques that can try to remedy that.  For example, how certain professionals can be encouraged or deterred from becoming a strong leader for the NHS.

How much do you think language that patients and professionals use is linked to that gender stereotyping and its effect on patient care and professional developments?

I think language is important and what underscores the way that gender is affected by language is when it comes to adopting a passive or active tone of voice: whether you are going to have something done to you or whether you are going to participate in something.  We do a lot of work about using active voice in our patient information because, as a general principle, it is much more empowering for patients.  Sometimes there is a disproportionate use of passive voice both for females and by females, which reinforce each other.

Within nursing this is a real issue by virtue of the fact that the majority of the nursing workforce is female.   I think there is a lot of work to be done but also great potential to have an impact on it, because you can achieve change, there can actually be a large number on your side.

Working with the nursing workforce to think about the language that we use is something that I feel really passionate about. It has a lot to do with how we see ourselves.  It goes back to assertiveness, the sort of language you use to speak about yourself is almost a self-fulfilling prophecy: it is how eventually you start to see yourself.  The more that nurses can be encouraged to use active leadership language about themselves, very slowly this will be how we will see ourselves and eventually how others will see us.

If you try to get people outside of your professional circle to see you differently, that is almost going the wrong way around.  If you don’t see yourself like that and your peers don’t see you like that.  So, we need to start talking about ourselves within that frame of reference before we can expect other sections of the healthcare environment to think about us in that way.

Thinking about the intersection of language and gender that patients use, I think this is particularly apparent around end of life care.  Female patients can use a lot of euphemisms and indirect communications to indicate pain.  Male patients can feel like they have to be quite stoic so would describe pain differently, probably in a more physical tangible way.  Whereas women can describe pain in a more euphemistic and ethereal way.  Language is hugely influential in that, as well as age and culture and stereotypes of what is appropriate and not appropriate to talk about.

Do you think we should be paying more or less attention to gender in healthcare? Do we need to be thinking differently about men’s and women’s health or should we actually try to be gender-neutral?

That is a very interesting question.  I am going to sit on the fence slightly, in the sense that I think that it depends on the individual; so I suppose my answer is ‘pay less attention to gender’. Give gender the same credence, no more no less, than you would somebody’s culture, somebody’s age, somebody’s personality preference. Some people will want lots of information, some people will want less, some people will want to be in hospital, some people will want to be at home for care, some people will want their families involved, some people won’t, some people will have a partner, some people won’t.  I think that all of those aspects to some extent will be affected by gender but I think I would be cautious about relying too heavily on gender and the role that has on the type of care that somebody wants.

Ultimately it comes down to what does the patient want from healthcare and I think that this can be affected by so many different factors.  For some people’s gender would play a huge part, for other people it wouldn’t matter if they were a man, woman or transgender.  It really does depend on the individual’s health situation.  I would be cautious of over assuming that gender would play a part in that, it needs to be led by the patient and they need to let you know whether it does or doesn’t.

The theme for this year’s International Women’s Day is #BalanceforBetter.  What do you think this means for healthcare?

I think this goes back to conflicting principles, and constantly being able to question, as a health professional, as a human being and as a patient, what is healthcare for, what outcomes are you trying to achieve and what does that mean for the person that is doing the caring and the one that is receiving the care.

To think of a global health example, it is very easy to go into a lower income country and say ‘the priority here is maternal health’; and actually when you dig a bit deeper, you find that the core of the issue might be the social determinants of health, eg health education, poverty reduction, or how to empower females to be more involved in household income.  I think it is about being willing look at things outside your own spheres of work, to almost loose your focus to get your focus and be sure that that’s your focus; to be able to let go of what you are thinking about right now to be able to come to the same subject.  It is about taking a leap outside to be able to go back to your original point.

Going back to #BalanceforBetter, I think the balance comes from three things: being able to accept that you might not know what the issue is, think about what you to improve, for whom, and go to those people and ask them what the best benefit for them would be.  Finally, be constantly ready to start all over again. Balance is about knowing but being willing to not know.