Integrating the Gender Perspective in Medical and Health Education and
1. Central questions, core issues
"I hid the pills (OCP) in a safe place. But, one day, my husband found them. He was furious. He threw them away, and he beat me." [battered woman at a Refuge, Kuala Lumpur]
"Its difficult for me to take the pill. My priest said it is not done for good Catholics. If I take it, I would be ashamed to say it during Confession." [Kadazan woman in a urban slum, Sabah]
"I really cant say No to my husband. What I can do, is to go and sleep with my kids."[Muslim factory worker and mother of seven, Penang]
These experiences are not unique to Malaysian women. Instead, they speak to womens general lack of control over their sexuality and reproductive health in both developing and developed countries. These expressed needs exist despite the availability of health services, modern medical technology and the overall improvements in maternal morbidity and mortality statistics, albeit with much variations between and within the First and Third World countries.
Indeed, womens lack of control over their bodies, inequalities in health status between men and women, and womens unequal treatment in health care, medical education and research are the major women and health concerns that require urgent, systematic and global intervention and change. This is so that we can put into action the commitments to women and health made in the 1994 Cairo Plan of Action and 1995 Beijing Platform for Action. The central question for us gathered here today at the meeting on women and health is, whether womens health concerns and needs can best be addressed by following the usual biomedical practices, education, research and policies?
Womens experiences and realities, part of which being voiced by the Malaysian women above, clearly testify otherwise. In fact, in most medical, health and prevention issues related to womens health, the central issue is male-female power relations, and not merely the lack of health services, medical technology or/and information [E. Fee & N. Krieger, 1994 ].
These realities thus urgently call for a gender analysis of health, which refers to a systematic study of how and why do diseases affect women and men differently. It also takes into account how factors of social class, race, education and other socio-cultural factors interact with gender to produce discriminating impact on men and womens health. Gender analysis is crucial to distinguish between biological causes and social explanations for the health differentials between men and women, and to understand that these gaps are outcomes of the unequal social relations between men and women, and not merely due to consequences of biology. Gender analysis will also accurately inform on diagnosis, treatment and prevention. At the same time, it will transform the biomedical and gender bias currently imbedded in medical education and research, so as to better serve the health needs of women.
2. Gender inequalities in health, sexism in medicine
A hierarchy of diseases is said to exist, whereby "womens diseases" are viewed as less important because of the diffuse symptoms in various parts of the body seemingly without a known cause, compared to "mens diseases" that have clear-cut symptoms and are diseases of vital organs. For instance, fibrositic diseases and depressive neuroses rank the lowest and these diagnoses are more frequent in women than men. In Norway, despite its reputed national medical insurance system, women may run the risk of getting less recognition, receive less monetary compensation, and thus poorer quality service. The disease patterns differ between men and women in several ways. Some diseases strike women and men at different ages e.g. women tend to contract cardiovascular diseases at an older age than men; some disease are more prevalent in women than in men e.g. thyroid gland disorder, anaemia lupus, eating and musculo-skeletal disorders; while some diseases like osteoporosis and rheumatic diseases are more serious in women than in men; and some diseases or conditions affect only women, such as, dysmenorrhea, cervical cancer, infections due to unsafe birth deliveries and abortions, female circumcision, reproductive tract infection (RTI) and urinary tract infection (UTI) due to poor sexual hygiene [Norwegian Board of Health, 1995, E. Royston & S. Armstrong, 1989].
Despite these facts, womens health needs are often regarded to be restricted only to reproduction. The gender bias is reflected clearly, such that, within medicine, womens health is relegated to only obstetrics and gynaecology; and within public health, all womens health needs are expected to be met by maternal and child health programs. This is because women are primary seen as mothers and wives, rather than human beings having health needs. Thus, womens non-reproductive health is either invisible or not emphasised. For instance, despite women having been part of the labour force for so long, their occupational health have often been ignored. Not only is womens health defined by their reproductive role, it is often misunderstood because women are always viewed as a homogenous group. In reality, womens health or illness, pertaining to reproduction or not, are differentially experienced according to social class, race/ethnicity and so forth. For instance, while among older women, breast cancer is more common among the rich, cervical cancer tends to affect more poor women than the affluent. Research has shown that black women, within each income level, are more likely to suffer from hypertension than white women [N. Krieger & E. Fee, 1994; V. Sivanesaratnam & ST. Teoh, 1996]. Such a social patterning of disease points to the general fact that womens health issues cannot be explained by sex/biology alone.
Instead, Doyal  posits that womens health and sickness be understood in the context of the patriarchal and capitalist nature of society - what she calls socialist feminist epidemiology. In looking at major occupational diseases affecting women, she pointed to the relationship between female socialisation and female roles on womens health. Depression is found to be a major occupational illness among housewives because women are brought up to express their problems in the form of depression [L. Doyal , 1994]. In reproductive health, such as contraceptive use and family planning, women lack decision-making power to negotiate about sex, childbearing and contraception as husbands assume sexual access and control. While a husband can, and often does, refuse to use contraceptives despite his persistent sexual demands, women find themselves caught in their conflicting roles as solely responsible for family planning, and at the same time are expected to be sexually available to their husbands. In some developing countries, ill women still need their husbands approval before they can go out to seek medical treatment or health care. Or, when they do arrive at the hospital, there are numerous medical procedures that require their husbands signatures. Thus, it is clear that gender roles and male-female power relations rather than biology that underpin womens health and well-being.
3. Medical education and research: gaps and gender bias
The preceding account showed how womens health and ill-health have been reduced to a matter of their biology, and how disregard for women has permeated throughout medical practice and the health services. It is reported that in the United States, such views were institutionalised within scientific medicine and the new public health by the first few decades of the 20th century. Thus, biologically deterministic views of sex/gender differences have since become a natural and integral part of the curriculum and research agenda in medical and public health practices [Krieger & Fee, 1994, p15]. Although the Hippocratic Oath, with its explicit clause of not giving women "pessary to produce abortion", can be said to be generally outdated and not quite held up as the exemplary standard to emulate, the 1983 amended Declaration of Geneva adopted by 35th World Medical Assembly still refers to "colleagues as my brothers" [British Medical Association, 1988].
Although the proportion of female students admitted to medical schools has been increasing from about 5 percent in the mid-1970s to 40 percent in the 1990s in America, the medical curriculum, however, does not "speak to womens health concerns". Moreover, both lectures and clinical skills are more often than not taught by white men, about white men and for white men. Gender bias is apparent even in the teaching of basic science and biomedical subjects, such as normal human body and its functions. For example, lectures on male genitalia could be spread over three days but none on womens sexual organs, because "men and women are basically the same". Medical textbooks still consider the male as the norm or reference point for all courses and regard women as exceptions to the male [E. Nechas & D. Foley, 1994, p 41].
The disregard for womens health in the medical curriculum is best reflected in the teaching of basic clinical skills, such as physical examinations. Medical students are taught how to examine the entire body, the head, neck, abdominal areas, the cardiovascular and neuromuscular systems, except the breast and pelvis. Instead, students have to resort to learning such basic skills vital to womens health care by practising on poor patients with breast illness who are already in pain. Alternatively, it has been alleged that students have been taught to do pelvic exams on anaesthetised patients who were undergoing a surgical procedure [E. Nechas & D. Foley, 1994, p.43]. These medical teaching practices have at least two serious implications that are adverse for womens health care. When statistics reveal that breast and cervical cancers are one of the top causes of death for women, such teaching methods of clinical examinations of womens breast and pelvis certainly would not contribute to the treatment or prevention of these top killers of women. The other more long-term insidious effect is that the habit of examining a woman in pain has come to be the basis of medical students learning experience of womens health in particular. Thus, until very recently when and where the use of teaching associates is practised, teaching medical students how to do competent, sensitive and painless breast and internal examinations for women have not been an integral part of the medical teaching practice. This explains why women expect and experience pain during what should be routine internal examinations, one of the many examples of unnecessary suffering which women endure when undergoing medical examination or treatment.
However, about 25 percent of medical schools surveyed showed that they do offer womens health electives, which are optional courses that address health concerns having special impact on women, such as, osteoporosis, incontinence, heart disease, breast cancer and menopause [E. Nechas & D. Foley, 1994]. It is not clear if such womens health electives touch on gender perspectives and gender analysis of health.
Surveying the medical curricula from two established medical schools taught at public universities in Malaysia showed that there have been recent attempts to balance the biomedical bias towards integration of the patient into the family, community and society. For instance, this is reflected in the objectives of the medical courses "to produce competent doctors with a holistic approach to the practice of medicine", and " who would be part and parcel of the health care team and the people" [UMMC, February 1998, p 2; Rashidah Shuib & Roziah Omar, 1996, p 4]. Despite such integrative innovations in the medical curricula, the latter is still strongly biomedical, with psycho-social and cultural courses being regarded as "soft subjects" [Rashidah Shuib & Roziah Omar, 1996, p 11]. With regards to clinical examinations vital to womens health, breast examination is taught by the general surgeon using women patients with diseases, such as abscess or tumours, formerly in groups of ten students but now with only one student at a time. Students learn about vaginal examinations while observing/assisting birth deliveries during the Obstetrics posting, and when women patients are anaesthetised for surgical procedures during the Gynaecology posting. It is said that for the male medical students, breast and pelvic examinations present considerable problems due to the relative unfamiliarity with the female anatomy, hang-ups about the female sex and sexuality, and patients reluctance to be examined by trainee students. There are no specific courses on womens health, whether integrated into the medical curriculum or as an elective. Women are studied as part of the family, especially as mothers in courses such as Family Health, once again stereotyping womens health only in the context of reproduction. Moreover, the approach to womens reproductive health is still predominantly biomedical. For instance, it is the biomedical aspects of side effects of various contraception methods that are emphasised to medical students. Although the latter are exposed to cultural and religious barriers to family planning given the multi-ethnic background of our patients, the underlying issues of male-female power relations affecting sex, sexuality and contraception are seldom discussed or even raised in the classroom.
It is heartening to note, however, that some innovative inroads have been made in transforming the biomedical bias of medical education in some of the other countries in the Asia Pacific region. For instance, the private medical college of Aga Khan University, in Pakistan, has introduced gender in the context of primary health care through its Department of Community Health Sciences (CHS). During the non-clinical years, medical students are taught subjects, such as, Role of women in health and Women and environment; and nursing students are exposed to social issues in health pertaining to women under the Culture, Health & Society course. The CHS has recently initiated a network called the Pakistan Reproductive Health Network (PRHN) consisting of medical and non-medical professionals, to promote reproductive health in the country and to benefit from the different (presumably including non-biomedical and more gender-sensitive) approaches to womens health (R. Zaman & K. Marvi, 1996). While in the Philippines, the public University of the Philippines, Manila (UPM) is rather committed to innovative programs that are responsive to the social aspirations and health needs of the Filipino people. Its College of Medicine offers the Integrated Liberal Arts-Medicine program which aims to provide medical students with as much social sciences and humanities as possible, so as to inculcate social awareness among them (P Ramoz-Jimenez & F Castillo, 1996). Although it is not certain whether social awareness necessarily includes gender awareness, at the very least the UPM medical curriculum seems less biomedical than some of the more conventional medical education taught in the region.
With regards to education for other health professionals, particularly nurses, it can generally be said that the curricula contain relatively more social science courses pertaining to health behaviour and patient care. However, whether they are informed about the gender perspective would depend very much on the respective teaching institutions and instructors.
Despite the fact that diseases, such as heart disease, depression, AIDS, affect women and men differently, many medical studies on diseases, treatments, and outcomes whether of low or high cost, short or long-term, have been carried out using all male subjects. It has been alleged that not only has gender bias "infected" medical research, but women have been systematically excluded from medical studies. This is evidenced by the following observations: women were not included in studies of heart disease; lack of funding on diseases which disproportionately affect women, viz. breast cancer; and the safety and efficacy of drugs being tested only on men but which would be dispensed to women as well. It has been reported that the National Institute of Health, the U.S. governments largest funding organ for medical research, had spent only about 13 percent of its total budget on womens health issues. A NIH-funded five year Physicians Health Study on intake of aspirin and reduction of heart attacks had studied 22,071 men and no women. A prospective study on health and ageing included only men during its first twenty years, despite the fact that majority of those over sixty-five years are women. As incredulous as it seems, one Rockefeller University project on the impact of obesity on the tendency for women to develop breast or endometrial cancer had only men as its study subjects [E. Nechas & D. Foley, 1994].
Generally, there certainly have been comparatively more critical or feminist analyses of medical research done and published in the developed countries than in the developing world. It is, however, important to note that particularly in the area of health research related to family planning in developing countries, gender relations are very often not considered for study. The Knowledge, Attitudes & Practice (KAP) survey research methodology that was universally used to determine the infamous "unmet need" for family planning in developing countries during the 1960s have been severely criticised to be both eurocentric and culturally biased [ JW. Ratcliffe, 1976]. Unmet need is conventionally defined as wanting no more children or wanting to postpone childbearing, but using modern contraception, such as the oral contraceptive pill, intrauterine device, condom and sterilisation. The unmet need estimate arising from KAP and the USAID-funded Demographic and Health survey data had become an important policy tool for conceptualising and designing population policies and family planning programs all over the developing world in the 1960s and 1970s [R Dixon-Mueller, 1993; YL Wong, 1995]. My contention with the conventional definition of unmet need lies in its dependence on modern contraceptives as the sole criterion for an effective means to either space or limit births, without any consideration for the prevailing use of traditional and non-program methods, such as, breastfeeding and withdrawal. In addition to its cultural bias, this universal measure gives no recognition to fertility regulation practices currently used by both women (such as breastfeeding) and men (such as withdrawal) in developing countries. Not only do such local methods lack side effects, are user-controlled, and involve men, but their success and sustainability have been based on some pre-set negotiations and understanding between the partners in their sexual relations. Such intimate and power relations between men and women are often ignored in family planning programs promoting modern contraceptives, which may explain why the latter have met with more failures than successes [YL Wong, 1995]. It is in such gender-insensitive family planning programs that both women and mens sexual and reproductive rights have been blatantly forsaken for achieving the economic and demographic goals of state population policies.
These gaps and gender biases in medical education and research mean that doctors have been practising mens health on women, which not only compromise the health and healthcare of women but may well endanger womens lives. Yet, scientists and medical researchers who exclude women in their research argued that it was really to protect a womans foetus since she could become pregnant during a clinical trial - for "womens benefit" so to speak. Womens menstruation would also complicate research and increase cost, not to mention the fear that such hormonal fluctuations would contaminate their data with confounders and outliers. These so-called reasons once again reflect the distorted view of what are normal body functions unique to women to be a "disease or medical condition". What is worse is the perpetuation of the mistaken but widely held theory that womens ill-health is due to their biology, to which nothing very much can be done to change or improve womens health and well-being - so, why bother to include women in medical research?
The underlying reason for all-male medical research and studies is that what is valuable to medicine is what is valuable to society; and it is the man, not woman [E. Nechas & D. Foley, 1994]. This is a part of the continuum of unequal gender relations, whereby society values mens work and lives over those of women. If all this while it is mens lives we are made to study in history, politics and the arts, why should it be different in medicine? Indeed, it has been alleged that the institution of scientific medicine does not only reflect discrimination against women in wider society, but through medical knowledge and practice, it serves to create and maintain gender divisions in society [L. Doyal, 1994, p 68].
4. Gender-sensitive medical education and research
What will be the new philosophy, values, or objectives, contents, teaching and learning strategies of these changes to the medical education and research, so as to guarantee the successful implementation of the 1995 Beijing Platforms recommendations on women and health, and mainstreaming gender into the health sector? The preceding discussion on gender inequalities in health and gender bias in medical education compels us to adopt a gender approach to medical education that would take full account of existing gender differences in health care provision at all levels. It would also emphasise on womens participation in the health system. The objective ultimately is to "train doctors to treat women from head to toe, and not just from the waist down" [E. Nechas & D. Foley, 1994].
Much can be learned and culled from the success and achievements of the womens health movements for the past twenty-five years. Through a network of social-action groups and womens health centres providing health care by and for women, the womens health movement struggled to demystify medical knowledge and had made it more widely available through non-elitist and non-authoritarian means. Validating womens own experiences of their bodies and their own observations of the physiological processes happening in their bodies, women challenged medical doctors "objective" clinical knowledge and argued instead that their own "subjective" knowledge is relevant to the understanding of womens health problems. In this way, the womens health movement have initiated the feminist health education practice, based on the development of these new skills and new areas of knowledge [L. Hunt, 1997; L. Doyal, 1994].
Lynne Hunt , after studying 73 womens health agencies in nine western countries, posited that the womens health movement have indeed developed a distinctive womens health care speciality (WHS). She has identified eight key features of the speciality and they are: women-only services; creation of woman-space; self-help and holism; feminist counselling and woman-to-woman support; feminist teamwork; diversified health care; information sharing and social action; and lastly, accessibility. For instance, Hunt explained that diversified health care refers to the different variations in women patients or users of health care - varied social class, sexual orientation, culture or ethnic groups and so forth. Whereas the medical care model treats women as a homogenous group. The Womens Health Speciality considers it important to create woman-space in a social, physical, and temporal sense. In this woman-space, women not only feel safe and valued, the home-like setting puts women at ease so as to avoid the impersonal clinical atmosphere associated with the medical setting. According to Hunt, the three ideologies of feminism, empowerment and the social model of health are the hallmarks of the womens health movement, and the pillars of the WHS. Yet, the application of these principles varies in accordance with each local situation. Under the WHS, the concept of health has been broadened from its biomedical base to incorporate the social context of womens lives. Hunt calls strongly to incorporate the WHS into tertiary curricula, stipulating that both feminist principles and empowering practice be taught within the framework of the social model of health. Difficulties will abound, especially those pertaining to appropriation and monopolisation of these principles, making real the risk that they will be co-opted and medicalized [L. Hunt, 1997]. Although the model of a womens health centre as it exists in Australia, Canada or the USA is not as widespread in the South-east Asian region, there are several women health groups and organisations focusing on reproductive health, particularly in Indonesia and the Philippines (personal communication with Lynne Hunt). Apart from the voluntary family planning associations in Malaysia, relatively few women organisations can be said to provide specific health services and health education to women. There is also relatively less information on the extent to which the experiences of such women health groups could be integrated into medical education in the region, due to lack of access to published studies or research.
Indeed, integrating the gender perspective into the medical curriculum by incorporating the principles and practice of womens health speciality described above will be a good beginning. Yet, how do we actually translate and operationalize Hunts WHS model within a medical setting? Firstly, such a transformation will involve drastic ideological changes, not mere reforms in the curriculum. Presently, medical students tend to concentrate solely on acquiring clinical skills without questioning the underlying values and philosophy of medicine. To many medical students admitted to medical programs which require no basic or general education in the liberal arts, and who have so far been streamed into the hard sciences, concepts of social justice, feminism, empowerment and social action are mere new terms and would have no meaning. Generally, medical students either do not or cannot conceptualise what they are learning because they are not taught to do so. How can this ideological gap be bridged and the appropriate pedagogy be applied?
Secondly, what explicit teaching methods and courses are needed in the lecture halls so that upon graduation, the doctor not only is competent in reproductive medicine and technology, but also could empower a woman patient to exercise her rights to abortion? How could a medical student, intern, a nurse or qualified doctor in the hospital save the mother who is lying at home, dying of postpartum haemorrhage but cannot come to the hospital without her husbands permission since he has gone out of town? Will they be able to recognise her rights over her own body and stand up against her husband and her husbands family, in a culturally-acceptable way? Thus, not only do medical students need to learn new ideologies and gender concepts, they must put them to action and bring change to the existing unequal male-female power relations that cause inequalities in womens health and health care. Thirdly, closely related to teaching methods is assessment. What innovative assessment will be suitable to measure the above values, attitudes, and commitment of gender-sensitive doctors-to-be?
With regards to strategy, is it better to set up a womens health speciality separate from medicine? Or, will integrating the gender perspective spirally throughout medicine be more effective? As much as health services specific to women need to be provided, will a separate womens health speciality, however, merely be "preaching to the converted"? Or, will it just become like any branch of specialised medicine?
Lastly, how do we mainstream gender into the health sector when gender inequalities remain the norm in the rest of society? Will this mean the conditional need for wider political change?
These are some of my burning questions with regards to integrating the gender perspective into medical education in general, and implementing womens health speciality model in the medical practice in particular.
5. Concluding remarks
We understand now that not only have the biomedical and gender-biased medical education and research system failed to address womens health concerns, they have also created and contributed to gender inequalities in health and sexism in medicine. As a result, sensitive and painless breast and pelvic examinations for women have not been an integral part of medical teaching practice and how this has caused unnecessary suffering for women undergoing treatment. Similarly, it is clear that due to the all-male basis of much medical research, doctors have been practising mens health on women, which both compromises womens health care and puts womens lives in danger.
Thus, we certainly cannot allow the gender inequalities in health and gender bias in medical education and research to continue. We must act promptly and globally towards a paradigm shift from that instilled since the eighteenth century, when medical education was first organised to mass produce medical doctors.
I would now wish to discuss the above questions on changes in the medical education and research with all present here today and jointly develop an action plan for gender-sensitive medical education and research.
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