Changing Perspectives on Sex and Gender in Medical Education

Abstract

Physical, behavioral, and social variations between men and women have always been apparent. By and large these variations have been thought of dichotomously and called “sex differences.” Each word in this phrase, however, raises discomfort: “sex” because it evokes “sexual,” and “difference” because it evokes discrimination. The scientific discourse on sex differences over the last decade has been dramatically influenced by these deeply ingrained cultural discomforts, resulting in the preferential use of the term “gender-based biology” that avoids both “sex” and “difference.” Furthermore, with the sole exception of reproduction, the life sciences have traditionally viewed sameness and uniformity as “the norm,” difference as “deviation from the norm.” In 1999, the Office of Research on Women's Health at the National Institutes of Health began to use a conceptual framework that is more technically accurate.1 In this definition sex refers to biologically-based differences (being male and female) and gender denotes those qualities that are culturally-shaped variations between men and women, or that result from social processes or expectations of being male or female. Women's health is also an ambiguous term. Educators frequently use it to describe a thematic connection between the new research findings about sex- and gender-based differences. In fact, women's health has been defined differently by many individuals2 and groups3 over the last 20 years. Early definitions focused on reproductive aspects of health and were based on a biomedical model. Later definitions broadened to include non-reproductive issues as seen over a woman's lifespan and within a sociocultural framework.4 Proponents from many fields have come together to advance the cause in interdisciplinary, inclusive discussion.5 In the context of the set of articles in this theme issue, women's health connotes the scientific knowledge about sex- and gender-based differences, and also includes a woman-centered perspective. A woman-centered perspective, in contrast to a discipline-based perspective, is rooted in women's real-life experiences. It gives value to female sex and female gender as being important factors in shaping health care services and for informing scientific investigation. Such a woman-centered perspective is offered as a remedy to the inaccuracies of “sameness as the norm” in science and medicine. In fact, “sameness” has propagated a norm based on the white male, as if this prototype were sex- and gender-neutral. While equality under the law and in economic opportunities is often best achieved in this sex- and gender-neutral manner, equity in heath care requires a respectful appreciation of difference. A woman-centered prespective in medicine brings equity to health care, research, and education. In fact, the value that women's health brings to medical education is in its power to enhance awareness that “perspective” is an intrinsic part of science and medicine. After all, the medical student is not a blank slate, but brings into medicine her or his cultural and educational perspective. The medical school brings its own perspective—its language and thinking process. The disciplines, with their impact on undergraduate medical education, contribute their own professional perspectives to the understanding of health and disease. And while, until recently, patients have been seen primarily from the physician's perspective, the patient's point of view is increasingly influencing medical practice. In fact, students, physicians, patients, professions, and educational institutions all learn and act from their individual perspectives, and all those perspectives need to be acknowledged, respected, and included. Women's health education, like women's health, also has no universally accepted definition. It is a collage of efforts that vary from individual elective courses to full integration across the medical curriculum.6 It is used imprecisely to describe both content and method, sometimes for a single condition, sometimes for a comprehensive curricular effort. What is certain, however, is that its very nature is interdisciplinary and inclusive. Readers of the articles on women's health in medical education collected in this issue should be aware that, because clearly-defined terms are still emerging, the vocabulary used by the authors is not uniform. FORCES CONTRIBUTING TO WOMEN'S HEALTH CARE Apart from the still-emerging lexicon that obfuscates understanding of the terms associated with women's health, historic, social, and disciplinary forces are expressed in the contemporary efforts to improve women's health care. Some see women's health care as the purview of the obstetrician—gynecologist; others see a need to incorporate the emerging scientific information on sex- and gender-based differences into virtually all specialties. There is also a women's “self-help” movement that encourages women to take responsibility for their own health. These perspectives on women's health care are, to some extent, encompassed by yet another force, the emergence of a group proposing the creation of a completely new, woman-centered discipline in women's health. A brief revisiting of these parallel, sometimes competing, forces and the perspectives they embody, is in order. Obstetrics—Gynecology During the 18th and early 19th centuries, women's health care could for the most part be equated with the management of childbirth. Both lay women healers and midwives dominated the field before doctors, mostly men, took authority over the birthing process.7 These physicians, initially trained by apprenticeship or in “trade” schools, opened lying-in wards in hospitals, and established the medical field of obstetrics.3,8 Gynecology, an offshoot of surgery, combined with obstetrics in 1930,8 becoming the profession within medicine that served women by its intense focus on reproduction and the reproductive organs. While men physicians became increasingly involved in the surgical management of childbirth and pelvic disorders, women physicians within obstetrics—gynecology leaned toward the safe-motherhood movement and its focus on birth control, introducing contraceptive practices and the nonsurgical aspects of the field.9 Female patients sought the care of obstetrician—gynecologists during their reproductive years, and often asked these specialists to render general medical care to themselves and to their newborns and infants. Both of these “extensions” of reproductive care evolved naturally because of women's needs and because of obstetrician—gynecologists' responsiveness to the women and babies who were the focus of their work. As medicine and health care specialized over the 20th century, many different types of practitioners delivered care to women, piecemeal or comprehensively. The term “women's health,” however, continued to be equated with reproductive care right through the 1960s.10 The American College of Obstetricians and Gynecologists has always had internal dialogues about the extent of its domain and the implications for its training programs, but these became particularly relevant as the definition of women's health expanded. Lay Women's Health Movements A lay women's health movement concurrently evolved as medicine became professionalized, taking many forms and reaching prominence in the last half of the 20th century.11 Fueled by the growing feminist movement and rejecting the medical model, its advocates proposed a woman-centered, self-help model of women's health care. When the Boston Women's Health Book Collective published the first edition of Our Bodies, Ourselves in 1970,12 it became clear that women patients were not happy with the existing state of women's medical care and with the way many physicians treated women patients. The dominant focus of biomedicine within health care and the physician's dominant role within the patient—physician relationship were challenged. Nurses, on the other hand, long involved in women's health care and education, were proponents of change, and for including a broader sociocultural context to understanding women's health and illness. Women were encouraged to take charge of their own health and to seek alternatives to traditional medical care. Also evolving at this time was the academic field of women's studies, which introduced the woman-centered perspective to scholarship within the biological and social sciences.13 All these events reflected changes in the sociopolitical environment in the United States, women's ability to control reproduction with the advent of oral contraceptives and legal abortion, and the increasing rate of women entering fields previously dominated by men. In the 1990s, a new wave of activism took form that included lay activists as well as women from government, academia, and medicine. Attention was drawn to inequities in funding for biomedical research, the exclusion of women from clinical trials, and the need to improve physician education about women's health. Women Physicians Women physicians were first trained in schools of their own in the 19th century. These institutions educated women doctors (and often women patients as well) in the emerging methods of hygiene and preventive care and “saw as one of their tasks the elevation of female health.”14 With the 20th century came the “scientification” of medical training and pressures from the American Medical Association (AMA) ranking system and the Flexner report15 for medical schools to be university-based, to own their hospitals, and to employ faculty with strong academic backgrounds. Many women's medical schools closed and the presence of women within the field declined precipitously. As medicine became more “science”-based, the 70-kg white male as “norm” became the dominant model. It was not until women returned to the ranks of medicine in large numbers in the 1970s, prompted by the influence of the women's movement and anti-discrimination legislation, that this “norm” encountered challenges.16 The Women's Health Specialty Movement The women's health specialty movement17 in many ways reflects the three other forces. In 1996, The American College of Women's Health Physicians (ACWHP) was founded by women physicians from different specialties, including obstetrics—gynecology, in response to a growing awareness of the mismatch between the disciplinary perspectives of their training and the women they were serving.18 Fragmentation in services across the life cycle and separation between mind and body, reproduction and medicine were receiving criticism from patients and practitioners alike. The founders of ACWHP propose that an interdisciplinary approach will advance the art and science of women's health, especially given the increasing foundation of a sex- and gender-based science, and add a new perspective to women's health care. Through the interaction of all the disciplines, and informed by sociocultural context, women's studies and sex- and gender-based science, a new approach to clinical practice should emerge. This perspective would remain within the tradition of “scientific” medicine, but by providing connectivity between the disciplines, and looking specifically at how mind/body/reproduction/medicine/environment influence each other in vivo, would bring breadth and especially depth of new knowledge as it applies to the health of women over their lifespans. CONVERGENCE AND DIVERGENCE As co-editors of this theme issue of Academic Medicine and as participants in the activities of the ACWHP, the Association of Professors of Gynecology and Obstetrics, and the National Academy on Women's Health Medical Education, we believe that there is too much to know and still to be learned, and too many expectations from women and the health care systems, for “women's health” to continue the historic competition for patients, between the sexes14 or among the specialties of medicine. Every specialty has a role to play in providing health care to women and in educating future physicians about the science and practice of patient-centered women's health. Although the disciplines may have common goals, there are important, distinct contributions for each to make. Obstetrics—gynecology will most significantly contribute if it advances the knowledge base used by all specialties to reflect the way in which reproductive science informs all of women's physiology in health and disease. It is likely to continue to be a leader in women's health education for students, by virtue of its clinical clerkship, which provides a unique focus on women as patients. Internal medicine has a major contribution to make by bringing sex- and gender-based science to the in-depth understanding of organ-based pathophysiology, thereby improving the health care of men as well as women. By training students in the care of both men and women, internal medicine provides a forum for contrasting and comparing men's and women's medical conditions and responses to therapy. Family practice brings the perspective of a biopsychosocial approach to an individual within a family system—the relational perspective. Including sex and gender will sharpen the lens of family-systems thinking and enhance the role of the physician within the family health care system. Pediatrics can contribute to the science of developmental differences and gender identification in boys and girls as well as differing perspectives of mothers and fathers in childrearing. Psychiatry should apply the growing understanding of sex differences in the development of mental illness and response to therapy as well as explore gender effects inherent in various models of psychotherapy. Surgery can be attentive to differences in decision making concerning surgical interventions in men and women, and to the impact of the menstrual cycle on inflammation, wound healing, pain management and outcome, and, like emergency medicine, has a major responsibility in recognizing and managing women subjected to violence. The specialty of women's health, as it evolves, will continue to contribute to all medical specialties by looking toward the future and providing a home from which a new woman-centered, interdisciplinary science and its faculty will grow. Its connection with women's studies could provide a broader model for scholarship linking the medical, biological, and social sciences. Other forces outside medicine will also continue to have important roles: The lay women's health movement will continue to influence health care and medical education, as women patients continue to demand access to high-quality services and continue their activism around public health and accountability. Nurses will increasingly provide primary care services to women, and because of their long experience with and depth of understanding of the woman-centered approach, be formidable partners in women's health care. IMPLICATIONS FOR MEDICAL EDUCATION Enduring improvements in women's health care will require changes in how medical students, residents, and faculty in all discipline are trained. Since half of the population is female, and women make the majority of health care decisions for their families, it is essential that women and their perceptions of their health care needs be met adequately now and in the future. Both the Report of a Survey and Recommendations on Women's Health in the Medical School Curriculum produced with the Association of American Medical Colleges (AAMC)19 and the Fifth Report of the Council of Graduate Medical Education (COGME) on Women and Medicine20 have highlighted the need for women's health to be integrated into medical education. If all specialties are making changes to better serve women, then all medical graduates need to have a working knowledge of sex- and gender-based differences and the skills to keep themselves informed and competent as the field of women's health becomes more defined. This is in accordance with the first report of the AAMC's Medical Schools Objectives Project, which describes four domains of altruism, knowledge, skill, and duty as well as recommending progressive curricular change guided by assessment.21 While each of these domains is important to becoming a competent women's health provider, competence will be assessed in the ability, from a patient's perspective, to apply all domains simultaneously. Such a patient-centered approach underscores the importance of including an appreciation of sex, gender, race, and cultural variation in medical education. No longer can we teach a view of a cell as a generic cell or of a person as a “sex- and gender-neutral norm” if we expect our students to deliver competent care. We also know that it is particularly important that all medical students learn how to access and use the growing database of information about women's health. They need additional tools with which to critically analyze the older medical literature, since much of it has excluded sex- and gender-based analysis of research findings and has excluded women and a women-centered focus from research. The future health care system will depend on many types of collaborations: between disciplines, educational programs, clinical care, and research. Most importantly, a mutually beneficial collaboration between medicine and consumers of health care will be achieved by adding a “diversity lens” to evidence-based medicine, one that widens the view to include sex, gender, culture, race, religion, socioeconomic status, sexual orientation, and whatever other ways individuals might vary. Each imperative—the needs to integrate women's health, to appreciate diversity, to understand appropriately and use the database of information, and to collaborate in new ways—has a role in shaping the direction of medical education, and each will influence the others. Reform and transformation, in health care and in medical education, require each other. Women's health is being integrated into the traditional curriculum through additions and modifications of individual lessons and courses, as well as through the weaving of curricular themes of varying breadth throughout the curricula. Similar approaches are being taken to include new knowledge in genetics, nutrition, cancer, and complementary/alternative medicine. The growth of these themes and the modification of an increasing number of courses is likely to lead to the re-examination of our traditional discipline-based structure. At some point, we must consider fundamentally restructuring the curriculum, changing it from discipline-driven to concept-based. Many educators have been calling for such reform for some time now.22 The current plurality of efforts in women's health provides an organizational framework that demonstrates new possibilities for all areas of medicine and has the potential to drive the co-evolution of reform and transformation in both health care and medical education. Most importantly, it provides a model for including the perspectives of all the individuals accessing the health care system along with the perspectives of those learning and working within the system.