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gender in medicine

Importan t but of low status: male education leaders views on gender in medicine
Gunilla Risberg, Eva E Johansson & Katarina Hamberg

OBJECTIVES The implementation of and communication about matters associated with gender in medical education have been predominantly perceived as womens issues. This study aimed to explore attitudes towards and experiences of gender-related issues among key male members of faculties of medicine. METHODS We conducted semi-structured interviews with 20 male education leaders from the six medical schools in Sweden. The interviews were analysed qualitatively using a modified grounded theory approach. RESULTS The core category important but of low status reflects ambivalent attitudes towards gender-related issues in medicine among male education leaders. All informants were able to articulate why gender matters. As doctors, they saw gender as a determinant of health and, as bystanders, they had witnessed inequalities and the wasting of womens competence. However, they had doubts about gender-related issues and found them to be overemphasise d. Gender education was seen as a threat to medical school curricula as a

consequence of the time and space it requires. Gender-related issues were considered to be unscientifically presented, to mostly concern womens issues and to tend to involve male bashing (i.e. gender issues were often labelled as ideological and political). Interviewees asked for facts and knowledge, but questioned specific lessons and gender theory. Experiences of structural constraints, such as prejudice, hierarchies and homosociality, were presented, making gender education difficult and downgrading it. CONCLUSIONS The results indicate that male faculty leaders embrace the importance of gender-related issues, but do not necessarily recognise or defend their impact on an area of significant knowledge and competence in medicine. To change this and to engage more men in gender education, faculty measures are needed to counteract prejudice and to upgrade the time allocation, merits and status of gender implementation work. Based on our findings, we present and discuss possible ways to interest more men and to improve gender education in medicine.

Medical Education 2011; 45: 613624


doi:10.11 11/j.1365-2923.2010. 03920.x

Department of Public Health and Clinical Medicine, Family Medicine, Umea University, Umea, Sweden

Correspondenc Gunilla Risberg, Departme nt of Public Health and e: Clinical Medicine, Family Medicine, Umea University, Umea SE 90185, Sweden. Tel: 00 46 907853557; Fax: 00 46 90776883; E-mail: guari g97@student .umu.se

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gender among students, doctors, 28,29 30,31 researchers and faculty members. Literature publis hed in the last few years shows that harassment and discrim ina- tion hurt not only the victims themselves and their organ isations, but also directly male the well-being of affect and female colleagues within the organi sation. 32 Gender bias, such as manifested in the neglect of womens hea lth issues and gend er stere otyping, has also been shown in educatio nal materi al and medic al textboo ks33,34 and in medical curr icula. 35,36 These insights have given rise to a discussion on how to prevent and avoid gend er bias in medici ne. One way would be to int roduce and implement a gend er-based perspe ctive and gend er-ass ociated issues in medical educat ion. 37,38 Here, teache rs are key persons. Repor ts from such implem entation efforts describe the hard work req uired to inform and inte rest teache rs. 3,3942 One obstacle is that gend er issues seem to be considered to represent womens issues. Studies carried out in the USA43 and Canada 44 showed that female medical faculty staff were more gender-sensiti ve and found gend er discriminat ion to be more of a problem than men did. A question naire study of medical teache rs in Sweden showed that women regarded gend er as more importa nt in professional relations than did men 45 and that men had more dismissive attitu des towards gender-re lated issues. 46 When gend er was integrated into medical curricula at all Dutch medical schools in a nation al project in 20022005, female teachers were more accepting of these changes than their male counter parts. 41 However, to establish gend er as an important field of knowledge among medical students, knowledge able and inte rested teache rs of both sexes are neede d.47 How do we enco urage more male teache rs to become involved? To the best of our knowledge no study has investigated male teachers attitu des towards and ideas about gend er-related issues in medicine. Cons equentl y, the aim of this interview study was to focus on infl uential male teachers attitudes towar ds and experiences of gend er-rel ated issues in medic ine as a possible way of better understa nding how to intere st more men in the subject and thereby improve gend er education in medici ne.
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INTRODUCTION

Gender has been recog nised as a key determ inant of social outcomes, including hea lth and access to health care. Gender also strongly influe nces career opportu nities. Consequent ly, knowledge and awareness of gender-rela ted issues are important among 14 medical professiona ls. In medici ne, the term gender is often mista kenly 2,57 used as if it were synonymous with biological sex. Yet gend er is a wider concept than sex and refers to more than biological diffe rences between women and 2,4,8,9 men . Gender refers to the consta nt, ongo ing social constru ction of what is consi dered to be feminine and masculine (do ing gend er), a construction based on the asymmetrical distribu tion of power between and socio-cultural norms about 811 women and men . Socio-cultural norms build on a dichotom ous think ing about women and men, which suggests the existence of inn ate and stable differ12 ences . The conc ept of gender, however, implies the possibili ty of change and negot iation. We all do 810 gend er in all kinds of social inter actions . In professi onal everyday life, doctors, too, do gend er. For exa mple, when they ask female pat ients more 13 than they ask male patie nts about their family, doctors are demo nstrating that they are influe nced by, and contribute to maintaini ng, the gend ered view that family matters are womens issues. An alterna tive way of doing gender would be to challenge this view by asking male patie nts about their family situati on as often as female pat ients. Thus, a gend er-aware perspective in medicine impl ies conside ration of life conditio ns, positions in society and societal expectatio ns about femininity and masculinity, along with biology in profes sional relations hips, when theorising about women and 4,10,14 men . Unawareness of gend er-related issues in medical professiona ls can lead to gend er bias in medici ne. Medical research has identified an abun15 17 dance of such bias in recent decade s. In clinical medici ne, studies have shown that diffe rences that are not evidence-ba sed occur in the invest igation and treatm ent of male and female patie nts. Most resear ch on this subject has been about 18 coronary heart disease , but there are also studies about many other conditio ns, inc luding kidney 19 20 21 disease , depress ion, colore ctal cance r, 22 23 Parkinsons disease, psoriasis, knee 24 13 osteoarthritis and neck pain. In academic medicine, there are reports about discrimination and harassment based on

METHODS

Recru itment We wanted to include male teachers who held key positions in medical educ ation and had exper iences

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of gender-rela ted issues in specific courses or in medical school curricula. Key positions were defined as those of dean, member of a medical school steeri ng comm ittee or committee for curricul um deve lopment, head of a course, and other positions implying lead ership and influe nce on the medical educat ion at the respective university. To identify eligible men, we turned to Equal Op portunities Committee officials and gend er resear chers at all six medical schools in Sweden. They recomme nded 29 men whom we contacted by e-mail and invited to part icipate in our interview study. A letter of introduction des cribed the backgro und and aim of the study and presented the rese archers. Two remi nders were sent to those who did not answer. Those who accepted the invitation were contac ted for interview; some of them recomme nded new men (n = 8), who were contac ted in the same way. By this process we contac ted a purp oseful sample of 37 male medical educators suiting our inclusion criteria. Five of them did not answer. Seven declin ed; out of these, four referred to lack of time, one to the fact that he knew the researc hers and two did not state why they abstained. The 25 who agreed to parti cipate were contac ted by telep hone by the first author to sched ule a time for the interview. Some interviews were resche duled and post poned several times and in five cases it was not possible to find a suitable time. A total of 20 men were interviewed, represe nting two to five interviewees from each school. As resear chers, we had no ind ependent relationships with any of the interviewees and did not know most of them, even by name, before the study starte d. Inte rviews All interviews were conducted by telepho ne by the first author in the autumn of 2005. Tele phone interviews were chosen to save time and travel expe nses because distances between universities in Sweden are long. Each partici pant chose a time when he could talk without being disturbed. The interviewer encour aged him to talk freely by posing open-e nded questio ns around the research topics (Table 1). In the interactive dialogue, the inte rviewer ende avoured not to pro be, but to obtain broa der and dee per inform ation by asking: Can you explain what you mean by []? or Can you give an exa mple of that? The interviews lasted 3060 minu tes, were tape-reco rded, transc ribed verbatim and made anony mous.

Table 1 Topics discussed in the interviews

What associations do gender and gender issues arouse in you? How did you learn about gender and become acquainted with gender issues? What are your experiences of working with gender issues in educati on? Do you have any ideas about how to interest other men in gender work? Do you have any ideas about how to implement gender in medic al educati on?

Part icipants The parti cipants were aged 4564 years. Seven represented pre-clinical specialties and 13 clinic al specialties, such as surgery, psychiatry and internal medicine. Fifteen interviewees were professors and five were senior lecturers. All of them held key positions as def ined above. Six had parti cipated in gend er implementa tion work and four had experience of teaching gend er-related material. Analysis Using a mod ified grounded theory appro ach with 49 an inductive qualitative research design, we conducted prelimin ary analyses of the tra nscriptions parallel to the interview process in order to let the data and emer ging theor ies refine the rese arch quest ions. By the time the data colle ction stop ped, the interviews were no longer adding new info rmation, but, rather, were conf irming our findin gs. All three rese archers first read each interview independ ently and made an open coding of the info rmants stateme nts, ideas and reflect ions. Keywords, expressions and cont radicto ry passages were noted. The codes were then compared, scrut inised and discussed; con nections and relations hips between the codes were noted and codes were sorted into preliminary categories. The researc hers conti nuously wrote memos and made concept maps of the ongo ing analysis. New interviews were successively added in a consta nt comparative analysis focusing on emer ging sub-categories, categories and a core category. Three categories emerged. The resp ondents ambivalence was summarised in the core category: Imp ortan t but of low status. Table 2 shows an exa mple of coding from quota tion to category.
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Table 2 Illustration of the coding procedure from quotation to category

Quotation I get so upset when there are unjustified differences in income and things like that. It is just stupid. And that women simply disappear as you go up the hierarchy ladder. I mean there is no difference in compete nce and intelligence between women and men

Codes Upset Injustice Stupid Women disappear No differences in compete nce or intelligence

Sub-categor ies Bystander stress witnessing of inequalities Waste of womens competence

Category Gender is important

The study was approv ed by the ethics comm ittee of the faculty of medic ine at our university. To secure anonymity, partici pants are not identified and no connec tions between quo tations and any specific person or universi ty are ind icated.

me ntioned a woman colleague as a source of inspiration. Two info rmants said that they had parti cipated in short courses on the subject of gend er, which had made them more motivated. Being bystanders witnessi g gender inequity in working n condit ions for doctors, such as in salaries and career opport unities, was a common reason for becom ing engage d. Interviewees saw such inequi ty as a waste of womenscompete ce: n I get so upset when there are unjustified diffe rences in income and things like that. It is just stupid. And that women simply disa ppear as you go up the hiera rchy ladder! I mean, there is no diffe rence in com petence and inte lligence between women and me n. Another reason was that stude nts treat male and female teache rs differently: I lecture about gend er tog ether with a female collea gue. We discuss the same issues, but the stude nts quest ion her accounts and her credibili ty much more than mine. Students demands and actions were described as importa nt driving forces: A group of our students has published a bunch of examples of gender-offensi ve remarks they have heard in class from their teache rs. That list has been a real eye-opener it is a remar kable lang uage we use. In Sweden, the governm ent has decreed that a gend er-related perspective should be implem ented in 50 medical school s. The governm ent has also ini tiated appraisals about gend er in medical schools carried out by the National Agency for Higher Educat ion and

RESULTS

Table 3 summarises our analytical findings. The core category importan t but of low status expres ses ambiv alence towards gend er and gend er-related issues in medici ne. It conta ins three categories that embra ce the parti cipants motives for conside ring gend er importa nt (gender is important), their doubts about the subject of gend er (but not that important) and the obstacles they had conf ronted when working with gend er issues (and not an easy task). We pres ent these categories and sub-categories. We use quo tations from the interviews to illustrate the findings. Gender is impo rtant All info rmants said that they thou ght issues of gend er were importa nt in medici ne. They declar ed a variety of incentives and sources for their inte rest in gend er issues. One overall motive was that gender is an important determinant of ill health: We need to take gend er into con sideration to succeed better with preven tion as well as with cure. More specific causes of mot ivation ranged from private experi ences to seeing the implementa tion of gend er-associa ted policies as a faculty duty. Quite often, info rmants ascribed their inte rest in gend errelated issues to the women in their own families and two interviewees specifically mentioned ideas passed on to them from feminist daughters. One info rmant

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but not that impo rtant
Table 3 Summary of analysis, sub-categorie s, categories and core category Sub-cate gories Determinant of health Inspiration from close women Bystander stress witnessing of inequalities Womens competence wasted Students demands A duty and decree Lack of time A threat to curricula Self-evident Exaggerates differences Concerns women only men have nothing to gain Question the definition of concepts Unscientific approaches Negative associations with feminism: male bashing Lack of knowledge Prejudiced attitudes Conservative and hierarchical discipline Little space for reflection Homosocial behaviour Hinders heteros exual excitement Not meritorious and not an easy task ...but not that important Categories Gender is important Core category Important but of low status

Although our interviewees said that they found gend er important, they also des cribed doubts about gend er-rel ated issues. Con tradictions emer ged between the diffe rent interviews, as well as within specific interviews. In one part of the interview, an info rmant would emphasise the importan ce of gender-related issues, but in another part he would quest ion them in diffe rent ways. Some of the quotations below illustrate how attitud es of doubt often appea red as negative examples when ideas of how to inte rest men and how to implem ent gend er in medical educat ion were discusse d. Many stated that they seldom took time to prio ritise gend er-rel ated work as a result of lack of time: I dont have the time, the research and the teaching and in my positi on there are so many assignments. There is no time for refle ction. I dont have a second left. Several interviewees expressed notions that gend er is overemphas ised (It cant be the primary subject matter) and conc erns that gend er-rel ated issues would take too much time from basic medical knowledge and thus represented a threat to the curricula: Gender implementa tion might take time from basic subjects, implying that stude nts will end up knowi ng less about glomerular filtration or about muscle groups around the sho ulder and I think that would be a real pro blem. A common belief referred to the notion that awareness of gender and equality is self-evident today because faculty staff include qualified women and more than 50% of medical students are female. As a result, gend er-related issues were consi dered to emerge naturally in clinical situations and there fore several interviewees saw no need for the implem entation of theory or special teaching efforts, at least not in their own departme nts or clinics: There has been an easy and natural atmosphe re at places where I have worked, so gend er has been no big deal and stude nts should have good tutors who convey this perspective in a natural way, not like lecturing or inst ructin g. Some interviewees seemed to think that comm unicating about gend er is only about exaggerating

the National Board of Heal th and Welfare . This has had effects on local university policies. Several infor mants mentioned this as an explan ation for their inte rest: It is my duty as one of the faculty leaders to implem ent gend er issues and then I have to be know ledgeabl e So I have boug ht some books and I try to read a little about it but I have not got ten very far yet, I am trying to learn.

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differenc s between women and men, rather than e about the problematis ing of diversity, and were critical of this: Sometimes gender is overemphas ised, because there is a large variation between individuals within the group of men and within the group of women. Its probably larger than the variation between the two groups. Several interviewees talked about gender mainly as belonging to women territor , criticised the focus on s y womens problems and opi ned that today men have nothing to gain from gend er-related discussion s: You could easily get the impress ion that the interpretati ons in gend er rese arch focus on neg ative effects for women only. It would be wise to broa den the analysis, to make it more generally applic able, and show that there are negative effects for men as well. That might be a way to get more men intereste d. Other info rmants consi dered it self-evident that women are more engaged than men because women belong to the subo rdinate group in the gend er hierarch y. One interviewee saw class and gender as parallel cases in this resp ect: After all, it was the employees who started labo ur unions, not the emplo yers. Several info rmants conveyed that equality ende avours too could be exag gerated and distr usted and questioned the definition of conce like inequity and pts discrim ination: You know, some women students are very militant. They notice if a supervisor says somet hing clumsy and put it on the notic eboard. I mean [for examp le], if a supervisor says, The blondes follow that doctor and the brun ettes come with me. That is not inequi ty or harassmen t; that is clums iness. Interviewees said they had perceived overtones, categor ical solutions and emotio ns instead of facts and thus were worried about unscientific teaching approaches: Positivistic rese arch; that is what convinces us. We can underst and other things too, but it never has the same deep impact. We must keep the scientific banner flying. Most informants acknowledg ed that gend erassociated issues include some related to the distribution of power and that gender equity might imply that men lose power and position: If you see it like this, there is one domi nant and one subo rdinate group and of course the dom inant group is seldom inte rested in surre ndering power and privile ges. However, when power-r elated aspects of gend er were touc hed upon, gend er was often associated with feminism, which some inform ants descri bed as intimidating and male bashing: Feminism is a moveme nt that has gone too far, and has become threate ning and hostile to many men. They descr ibed female colleagues working with gender and gend er resear chers in a negative light, as disappo inted feminists, directed by ideology and bitterne ss rat her than by scientific curi osity: Several feminists and gend er resear chers seem to belong to a special category of peo ple who are dissatisfied with their situation and blame everything on their gend er. They give many men an excuse to hold on to their prejudi ces and to conti nue their chauvinist attitude s. One parti cipant, comment ing on male bashing and on how men can feel abused in discussions about gender, proposed a constructive appro ach and conclu ded: Dont blame the men; blame the idea of gend er roles that both men and women embr ace. and not an easy task Most parti cipants described not only their own doubts, but also how they had enco untered scepticism or indiff erence to the subject of gend er from other colleagues. They also described structural const raints. These were factors that had obstr ucted their work with gend er-related issues. They considered insufficient knowl dge about gend er to be a major problem, both e among colleagues and in medici ne as a whole. For exampl e, they noted a lack of awareness of subtle ineq uities, such as how men and women are diffe rently treat ed in confe rence rooms and in examinatio ns. Prejudiced attitudes were also described as a major obstac le: Its about attitu des, you know, and that is difficult. There are too many prejudices from all parti es, including myself.

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Interviewees percei ved a huge need for infor mation and discussion at local meet ings for teach ers, at nation al gatheri ngs, at congresses and when discussing curr icula and sched ules: It is very important to work with conscious and uncons cious atti tudes among teache rs in order to teach and comm unicate gend er. Some partici pants des cribed med icine as a conservative and hierarchical discipline involving an enormous cramm ing of biological facts, leaving very little space for reflectio As a conse quence, n. they had met a relu ctance to change and to consi der new perspectives such as those rela ted to gend er: There are defen ce mecha nisms and aggr essiveness from groupings that claim that there are no proble ms conc erning gender in medical educat ion. These grou pings focus only on biological differe nces and deny that there are social and socio-cultural gend er aspec ts. They also comment ed on the tende ncy of men to choose other men to fulfil certain roles, thus demonstr ating homosocial behavour and a false belief in i gend er neut rality: Men in leading positions say they consider com petence only, but in reality they vote for or choose friends whom they know and have collabo rated with, most often other me n. Another idea that several info rmants said they had observed in male colleagues was that applying a gend er-based perspe ctive might take away the fun or hinder heterosexual excitement, thus dimin ishing the special relation and excitement that exists when there are women aroun d: You know, men are concerned nowadays about how to keep up the nor mal [de gree of] excitement between the sexes. All these obstacles meant that applying a gend erbased perspe ctive is not prio ritised at medical faculties, is not considered meritorious and is therefore met with scepticism: It gives [you] no credits and qualificatio ns in your CV, it gives no money it is hard to attract peo ple to gend er work.

DISCUSSION

This interview study found that key male members of medical faculties in Sweden held ambivalent views on gender in medici ne and conside red the subject to be importa nt, but of low status. To a certain degree, they all found ge nder importa nt. As doctors, they had seen the impact of gend er on health and, as bystanders, they had witnessed ineq ualities and the wasting of womens compete nce. They were inspired by students dema nds and they regarded them selves as duty-bound by official decrees to inclu de gend erbased material into the curriculu m. However, they mai ntained many doubts. They asked for facts and knowledge, but at the same time they down graded gend er-rel ated issues as self-evident and questioned specific lessons and gend er theory. Gende r-based perspectives were consi dered to be unscie ntific, to exag gerate differences and to be male bashi ng, especially when power-related aspects of gender were discussed. Experie nces of obstacles, such as prejudices, hiera rchies and homosocial behaviou r, and of gend er-based perspectives as hindering heteros exual excitemen t, had made educat ion about gender difficult. We will comment on our method before we discuss our findings. On method Twelve of the 37 men who were contacted decl ined to parti cipate. They all held similar positions and fell into the same age range as those who consented to be interviewed. We assume that those who agreed to parti cipate may represent those most interested in gend er-rel ated issues. This may imply that the decliners were even more ambivalent about the subject or found gend er to be less important, and thus we are unable to report all aspects of resistance and percei ved obstacles. Four of those who abs tained referred to lack of time, and ano ther five were not interviewed beca use of proble ms in finding a time for the interview. Citi ng lack of time as a reason for non- partic ipation may indicate that the resp ondent did not prio ritise genderrelated issues, but it may also be indicative of the work overload of educat ion lead ers. Tele phone interviews were chosen as convenient because interviewees were spread all over the countr y. However, the lack of face-to-face contact between interviewer and interviewee may have made the dialogues more imperso nal. However, the impress ion

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of the interviewer was that most of the men talked willingly and fluently, and that the data were enri ched by the many personal exper iences described. One man abstained from participation because he knew the resear chers. Ot hers may have recognis ed the resear chers by name as gend er resear chers, which may have led them to try to express themselves in politically correct ways. This we do not know. However, argu ments both for and against the implement ation of a gend er-rel ated perspe ctive appea red in the full data. Findings in qualitative rese arch do not represent proof, but, rather, consist of descriptio ns and interp retations. Our method for select ing partici pants and hol ding interviews with 20 teache rs in key positions at Swedish medical schools has limita tions. We cann ot lay claim to representat ivity and gene ralisabil ity, but, rather, we aim to make our results recognisable and transferable to other 53 contexts . That all three rese archers worked together on the analysis represents a stren gth of this study. Analyses were discussed jointly and disagree ments were subje cted to scrutiny in order to 54 obtain trustworthines s. On findings Our key faculty leaders were able to justify why gend er matters and to describe sources of inspiration for the implem entation of material on gender-based perspectives. This is important inform ation on which to build. For instance, developi ng mens interest in knowledge of gend er as a det erminant of ill health might expand the relevance of gend er for both women and men. Research of this kind, such as on how men may be under -diagno sed and women over-di agnosed with depressi on, has recently been 20 presen ted. The bystander stress experienced by men as they watch the wasting of womens competence or as they witness the down grading or harassme nt of women is also recogn ised as a gend er-rel ated issue for men and may serve as a basis from which to build allia nces 40,41,43 between women and men . Our finding that students actions and dema nds were greatly infl uential in putting gend er onto the agend as of faculty leaders is important. Students may think that their engagem ent has little impact on the way curricula are planne d. In this study, students actio ns stood out as represent ing important eye-openers to faculty staff. However, the male teache rs also des cribed why gend er was not that important. A recurring theme was their lack of time as teache rs, but they also cited lack of time and space for gend er-rel ated lessons in curric ula. Few infor mants had themselves prio ritised attenda nce at courses or lectures on gend er-related issues. One reason for conside ring specific lessons as unneces sary was the belief that gend er-related issues were self-evident and would emer ge naturally. This is in line with reports from an Australian med ical school at which the clinical teac hing faculty staff believed that gend er-related issues did not req uire specific teach ing time because they con sidered that approp riate attitudes would be learned by stu dents in the process of observing teachers inter actions at 40 the bedside . Such a belief disregards gend er as an area of com petence and knowledge and may contribu te to its low status. We would never claim that stude nts will absorb cardiology simply by being near and observing cardiologist s. Another hindran ce was that gend er-rel ated issues were seen as being overemphas ised by, for instance, a perceived failure to take diversity into accou nt. Mod ern gender theory, however, does indeed emph asise diversity within groups of men and 55 wome n and stresses the fact that other hiera rchical systems intersect with gender in rela tion to the 56 opport unities and positions available to individuals . Spokes persons for a gend er-based perspe ctive in medic ine should rememb er that focusing almost exclusively on biological and behaviou ral differences when communicating about gender implies an overly narrow focus that might restrain male as well as female doctors from engagi ng in gender issues. Criticisms also conc erned the comm unication styles used by female colleagues in gender research and educat ion. Descri ptions of these women as disa ppoi nted feminists who use overtones and emotio ns rather than facts very definitely place them outside the scientific medical field. Given the enormity of the work carried out by many women pioneers during the last few decades to int roduce gender- associated issues in medic ine into curric ula at Swedish medical schools, such harsh comments came as a surprise to us. Obviously, the way gend er-rel ated issues are discussed can cause irrit ation. The project lead ers of a Dutch programme desig ned to mainstream gend er-related issues were urged to comm unicate 42 carefully to avoid resistance . However, focusing on form more substantially than on content is a way of disre garding and down gradi ng an issue. There is also a risk that uncons cious techn iques of suppressi ng 57 indivi udals, such as by blaming individual women or

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groups of women for the chauvinistic attitu des of men, as exemplif ied in this study, will come into play. Most inform ants gave examples in which issues relat ed to gend er inclu ded hiera rchies of power in which women belonged to a subo rdinate group. However, when educati on about power relations was me ntioned, interviewees often expressed perceived associations with feminism and with fighting on the barrica des. This finding adds to the existing body of knowledge in a meani ngful way: important gender inequalities in med icine were relabelled as belon ging within the remit of ideology and politics, and as falling outwith the objective medical world. Similar findings were described in a Dutch study with educ ation dire ctors and agents of change. Powerassociated differe nces between men and women and gend er ineq ualities in health were framed as 42 feminist political issues and not as medical issues. Moreover, an Australian study report ed that med ical staff were relu ctant to engage in uncom fortab le discussions that might challenge the notion that all 40 people are treat ed equally and identic ally. A not able intricacy describ ed by our parti cipants conc erned the idea that men have not hing to gain from assuming a gend er-based perspe ctive as it will take away fun (i.e. heteros exual excit ement). Such a fear may help to explain resistance to engagem ent with gend er-assoc iated issues. It may also bring to the fore refle ctions on how heteros exual rela tions are organ ised. Are inequity and gend er stere otyping prereq uisites for heteros exual excitement? Amusing flirtat ion in the medical profes sional arena was des cribed in an earlier interview study with doctors, in which such inter action was discussed as being constructed by the eroti cising of super- and subo rdinate 58 relation ships. Implicat ions for medical edu cation The conside rations of key male faculty leaders are informative in deve loping our understan ding of difficulties in the implementation of genderassociated work. We will now discuss possible improveme nts in gend er education in medici ne and ideas of how to inter est more teachers, both men and women, in the subject. Our suggestions are summarised in Table 4. The low status of gender has been described in 4,40,41,59 earlier resear ch. A contributing factor as shown in this study is that gend er is not always ackno wledged as an area of compete nce and scientific knowledge. To establish gend er as a field of knowledge, medical educat ion boards and course

Table 4 Suggestions for how to improve gender educati on in medicine and how to interest more faculty members, including men

Establish gender as an area of scientific knowle dge Define learning goals, time allocated and examinations of gender in the curriculum Encourage discussions among faculty members about the nature of scientific knowledge Show in practice that gender involves both men and women Include literature and examples of aspects of gender and gender bias in mens as well as womens lives Involve both men and women in education about gender Broaden gender educati on Focus not only on biological and behavioural differences, but also on similarities between women and men, and diversity within the groups Tackle teachers own doubts Call attention to the perception of male bashing and discuss ways to avoid it Focus on the structural rather than individual aspects of power Allow teachers space to reflect on their own experiences of and attitudes to gender and education about gender

leaders need to be clear about defini tions of learni ng goals thro ughout the curric ulum and to allocate time in the respective courses. Regular examination of students on gender- associa ted issues also represents a way of improving the status of gender-rela ted 60 work and making it more merito rious . In addition, clear decisions on the part of deans and heads of departments would help teache rs who cite lack of time to prioritise the matter. Another way to tackle the low status of gend er is to enco urage discussions about the nature of scien tific knowledge among faculty staff. Criticism of gend erassociated issues as unscientific because they have social and political connotat ions raises quest ions about what is consi dered good and valid resear ch in medical society. A hiera rchy prevails among differe nt fields of resear ch in med icine, among which there is competition. Tradition al biom edicine, with its alleged objectivity and neutrality, often claims the right to define the field. Other research traditio ns, such as gend er-associated researc h, end up in a low-status group, sometimes def ined as something other than 4 science, as in the critique in this study. We argue that it is important that teache rs are stimulated to refle ct on how they think about scientific knowledge and learn ing processes and are given time to do so. The

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biologist Fausto-S terling has argued that the way someo ne teaches science depends on how that person thinks about the nat ure of scientific knowledge. She emphasises that, in todays world, teachers must place the scientific matter in a social conte xt in order to make use of their knowledge. This means that a teacher does not lose the scientific essentials of the course content if some traditio nal details are left out to make space for expan ded coverage because the value of what students learn does not lie in a 61 specific set of facts, but in a way of think ing. Accordingly, we argue that educato rs should not worry that teach ing about gend er-ass ociated issues will take time away from teaching about basic medici ne; what matters is that we teach about how to interp ret and unde rstand differe nt aspects of health and disease. To improve gender educatio n, both men and women must be involved. A few info rmants in our study had noticed that male teac hers were taken more serious ly than female teache rs when teaching about gend er. Accordingly, bring ing more male teache rs into gend er education in medic ine might improve the status of the gend er-based perspe ctive. Earlier resear ch has shown that mainstream ing and implem enting a gend er-based perspective in medici ne is facilitated by alliances between persons (wome n) aiming for change and senior 39,40,42 male faculty leaders hip. There is, however, an inherent dilemma in this strategy: improv ing the status of gend er educat ion by involving more men in it may endo rse the asymmetry of the respective status of men and women. The solution replicates the problem. Never theless, involving more men in gender educat ion is also a way of showing in practice that gend er conc erns both men and women. Several of the male faculty leaders perceived gender-re lated issues as mainly womens issues. This indicates that gender education ought to be broa dened. Gende r-associated issues and gend erinflue nced rela tionships have impact on men as well as on women and it is important to discuss this in medical educat ion. The norms of masculin ity, like those of femininity, imply rest rictions and entail specific conseq uences, chal lenges and difficulties. For example, there has been some discussion as to how gend ered expectations of men can lead to expo sures to risk, result ing in higher mortali ty and poorer quality of life compared with 62 women . Moreover, gender bias affects not only women but also men. There are reports that men 20 63 with depressio n and men with migrain e tend not to be diagnosed properly. Citing such examples may demonst rate that men do have somet hing to gain from sup porting a gend er-based perspe ctive. Resistance to the power- associated aspects of gend er can seem hard to tackle. We find that the comme nt made by one interviewee Dont blame the men; blame the idea of gend er roles that both men and women embra ce is illumin ating and summar ises most of our discussion. It illustrates the thin line negoti ated by comm unicat ors on gend er and des cribed by Verdonk et al. as the line between being conside red confident and determ ined, which is rewa rded, and being judged as assertive (too pushy), 42 which causes resistance . Even if gend er educators try to focus on the gend er-based system with its gend ered roles and asymmetry of power as a system upheld and reprodu ced by both women and me n, individual men may, and do, feel blamed and perceive the power-rel ated aspects of gend er as bel onging to the realm of politics and ideology. To channel this frustration into dialo gue and reflect ion, it is important to arrange faculty educati on programmes on gend er and also to discuss the risk of male bashing in order to find ways of avoiding it. One appro ach in such a programme would be to int roduce theore tical knowledge and facts about structural gend er patte rns. Changing the focus from an individual to a structural level may make the powerrelated aspects of the subject of gend er seem less intimi dating. Another app roach would involve making space for refle ction on ones own doubts and mot ivation.

Contributors: all three authors conceived and designed the


research and undertook the analysis and interpretation of data. GR carried out the interviews and drafted the article. EJ and KH conducted the critical revision of the article. All three authors read and approved the final manuscript. Acknowl dgements:none. e Funding: none. Conflicts of interest: none. Ethical approval: the Ethics Committee of the Faculty of Medicine, Umea University approved the study (ref. 05037 O ).

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