There is a history of gender bias in medical education and practice. Research has shown that this bias extends to the psychiatric field as well. Through material presented to medical trainees-in classes, textbooks, research reviews and the like-subsequent thoughts and actions may be negatively biased against women. A review of the ways in which biases are conveyed is explored, as well as suggestions for reducing, eliminating and preventing these biases in medical education.
In the early 1970s, influenced by the supporters of the feminist movement, educators increasingly recognized the potential of the instructional materials employed from grade school through college in influencing gender role stereotypes. Hence, there was an impetus to introduce Title IX of the 1972 Education Amendments Act to reduce gender stereotypes in educational materials used in federally funded primary and secondary schools (Minority Health Improvement Act, 1994).
The increased awareness of sexism and the role of training and professional development in perpetuating sexist values similarly compelled many professionals to examine the ideologies and methodologies employed in their disciplines for the potential of gender bias. Often, such bias conveyed stereotypic representations of men and women, but nonetheless, imparted strong value messages to trainees. For example, in a review of psychology texts, Denmark (1982) observed that women were presented in photographs as mentally ill or as passive participants in psychological research, e.g., looking on while a male investigator conducted an experiment. Males were more often depicted as therapists or researchers.
Gender disparities in the provision of medical care have recently received increased attention. The causes for such disparities are multi-factorial and may emanate from educational experiences and attitudes presented in medical training (Table 1). Overtly or covertly expressed attitudes toward women conveyed by instructors and supervising attendings are potentially influential on medical trainees also.
More subtle influences on the medical trainee include the amount of attention devoted to the study of clinically relevant issues and disorders predominantly affecting, or specific to, women. This can include the extent to which these topics are addressed in texts, lectures and reviews of relevant clinical literature.
Women's health-related topics may not be incorporated into basic medical training, as they are viewed as more specialized, possibly resulting in their omission from basic health care provisions. For example, it is not uncommon to note that breast and pelvic examinations are routinely omitted on patients admitted to hospitals despite the mandate of "complete physical examinations."
It is common for clinical research to overlook or exclude women to avoid hormonal influences on study results and omit women of reproductive age to avoid potential fetal risks. Consequently, results of clinical investigations based upon samples of men may be inappropriately generalized to women (Cotton 1990a, 1990b).
There have been increasing efforts on clinical and research levels to address gender bias. The early 1990s saw the National Institutes of Health establish the Office of Research on Women's Health and the Women's Health Initiative. Medical journals, such as the Journal of Women's Health, have been established to address issues pertaining to women. There has been some discussion of the development of a specialty in women's health, and several medical centers have been established nationwide with an exclusive focus on women's health.
Studying Gender Bias
Gender bias in medical training, and its influence on the medical trainee, is not readily amenable to scientific inquiry. Of those items listed in Table 1, only a few can be objectively studied. Furthermore, the resulting influence on the trainee remains unclear.
There are concerns that gender-biased instructional materials can impart values that are subsequently incorporated into clinical practice, as a great deal of a medical student's time is spent reviewing such texts. Gender bias in text content, unlike some items listed in Table 1, can be objectively quantified, e.g., by social role and stereotypic representations and in the frequencies with which men and women are portrayed in case scenarios or as models.
Previous investigations of gender bias in anatomy or physical diagnosis texts have noted that illustrations of male models exceeded those of female models (Giacomini et al., 1986; Mendelsohn et al., 1994). Consequently, investigators have suggested that medical students may be less familiar with female anatomy and are at risk for developing biases such as the male body being the "norm" (Mendelsohn et al., 1994; Nechas and Foley, 1994).
In 1999, Leo and Cartagena examined whether bias was present in psychiatric texts. Introductory-level texts were selected, as these are more apt to be used by medical students in psychiatry courses and during clinical clerkships.
Of the clinical case vignettes examined in this study, a disproportionate number featured male protagonists (Table 2). In five of the six texts reviewed, the use of the male protagonist exceeded that of females; significantly fewer female subjects were employed in four texts.
The propensity to use the male subject was not an artifact of depicting psychiatric disorders with higher prevalence rates among males. In fact, females tended to be subjects of vignettes illustrating disorders with higher prevalence rates among women, and likewise for males. Thus, protagonist gender was generally consistent with known epidemiologic trends of psychiatric disorders. Vignettes illustrative of disorders in which the prevalence rates are unknown or are equal among men and women, however, tended to feature male subjects.
Interestingly, only two texts dealt with disorders unique to women. One featured a single vignette describing premenstrual dysphoric disorder, and the other featured a single case of postpartum psychosis.
In summary, research has shown that women, who comprise more than half the population, and the psychotic disturbances unique to them are underrepresented in clinical vignettes in psychiatric texts despite their predominance in psychiatric practice.
The tendency to employ male subjects for illustrative examples has been observed in a variety of texts from grade school through college and subsequent professional training. The study on gender bias in psychiatric texts expands on work focusing on gender disparities in other disciplines, such as anatomy and clinical medicine, taught to medical students (Giacomini et al., 1986; Mendelsohn et al., 1994). The trends observed among psychiatric texts are, therefore, not unique to psychiatry but appear to reflect broader social biases. Nonetheless, several measures can be undertaken to correct the problem of gender bias in psychiatric education (Table 3).
Editors and authors of psychiatric texts can, in future editions, ensure that selection of subject gender in case vignettes parallels known epidemiologic trends or patterns of psychiatric service utilization. In this way, subject gender will be consistent with trends observed in the clinical setting. When these trends are unknown or unclear, a gender equitable approach can be a consideration (Scott and Schau, 1985).
Whether or not authors and publishers of psychiatric texts respond to the above suggestions, psychiatry instructors will likely have the more critical role in addressing gender bias. First, the problem of gender bias can be surmounted when one considers that gender can enrich our understanding of psychiatric principles. Clearly, gender differences exist with regard to epidemiologic and prognostic information regarding psychiatric disorders; therefore, every effort should be made to describe how the presentation, course and prognosis of psychiatric disorders differ for women and men. Second, students may benefit from having their attention drawn to the gender bias in educational materials and clinical research. The heightened awareness will attract a critical review of the limitations in clinical research and training and may impart the importance of greater sensitivity to the issues of gender as students advance in their careers, some or all of which may involve teaching of subsequent generations of medical trainees. Third, incorporating a section on women's health into the psychiatry curriculum may foster increased sensitivity to the full spectrum of issues and experiences affecting women's health (Spielvogel et al., 1995).
Future Avenues of Research
Previous research has demonstrated that physicians react to, evaluate or treat complaints made by male and female patients differently. For example, men receive more extensive evaluations and investigative studies than women, despite presenting with identical complaints (Bernstein and Kane, 1981; Council on Ethical and Judicial Affairs, 1991; Tobin et al., 1987). The differences in treatment and evaluation of men and women may be, in part, attributable to prejudices and misrepresentations of disorders as manifested by women in the medical literature (Lennane and Lennane, 1973; Scully and Bart, 1973). Whether a patient's gender influences the assessment and treatment of their condition, and how this might be communicated in psychiatric texts, warrants investigation.
Ultimately, it is hoped that when men and women are treated differently by physicians, it is based upon an awareness of the aforementioned gender differences and not faulty assumptions, attributions or misperceptions about men and women conveyed, implicitly or explicitly, in medical training.
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