MainstreamingMainstreaminga Gender Perspective into a Gender Perspective into the Medical Curriculum: the Medical Curriculum:

Why Bother? Why Bother?

Ann-Maree NobeliusAnn-Maree NobeliusFaculty of Medicine, Nursing and Health SciencesFaculty of Medicine, Nursing and Health Sciences

Monash University AustraliaMonash University AustraliaMonash Centre for Medical and Health Sciences Monash Centre for Medical and Health Sciences

Education Seminar Series,Education Seminar Series, 1717thth June 2003 June 2003

Ann-Maree NobeliusAnn-Maree Nobelius

Monash graduate, Physiology and Monash graduate, Physiology and Pharmacology & Masters in Reproductive Pharmacology & Masters in Reproductive SciencesSciences

medical research backgroundmedical research background further studies in sociological research further studies in sociological research

methodology particularly gender studiesmethodology particularly gender studies fieldwork for PhD in Public Health on AIDS in fieldwork for PhD in Public Health on AIDS in

Uganda with UK MRCUganda with UK MRC Employed by School of Rural Health to report on Employed by School of Rural Health to report on

Gender Issues in Rural Medical Practice ProjectGender Issues in Rural Medical Practice Project Project Officer for Gender Working Party with Project Officer for Gender Working Party with

goal of mainstreaming a gender perspective goal of mainstreaming a gender perspective into entire curriculuminto entire curriculum

Outline of Outline of PresentationPresentation WhatWhat is gender mainstreaming?is gender mainstreaming? WhyWhy bother? bother? WhoWho is doing it/what has worked is doing it/what has worked

what hasn’t?what hasn’t? WhatWhat do we want to achievedo we want to achieve & &

HowHow do we do it?do we do it? Costs & BenefitsCosts & Benefits

DefinitionsDefinitions

What is the difference between What is the difference between sex and gender?sex and gender?

Sex = male and femaleSex = male and female

Gender = masculine and feminineGender = masculine and feminine

SEXSEX

refers to biological differences; refers to biological differences; chromosomes, hormonal profiles, chromosomes, hormonal profiles, internal and external sex organs.internal and external sex organs.

GENDERGENDER

describes the qualities that a describes the qualities that a society or culture delineates as society or culture delineates as masculine or feminine. masculine or feminine.

It’s culturally definedIt’s culturally defined

‘‘man’ = male + masculine social man’ = male + masculine social rolerole

a real ‘man’, ‘masculine’ or ‘manly’ a real ‘man’, ‘masculine’ or ‘manly’

‘‘woman’ = female + feminine woman’ = female + feminine social rolesocial role

a real ‘woman’, ‘feminine’ or ‘womanly’a real ‘woman’, ‘feminine’ or ‘womanly’

Misunderstandings…Misunderstandings…

‘‘gender’ does not mean sex, female or gender’ does not mean sex, female or feminismfeminism

‘‘a gender perspective in medicine’ is not a a gender perspective in medicine’ is not a euphemism for women’s health, feminism or euphemism for women’s health, feminism or for men needing to ‘get in touch with their for men needing to ‘get in touch with their feminine side’feminine side’

at times impossible to differentiate the at times impossible to differentiate the biological from the social determinants of biological from the social determinants of health; convention dictates the use of health; convention dictates the use of ‘gender’ rather than ‘sex’ in those cases‘gender’ rather than ‘sex’ in those cases

misuse of terms is widespread (we use WHO misuse of terms is widespread (we use WHO and UN definitions)and UN definitions)

MEN HAVE GENDER TOOMEN HAVE GENDER TOO

A gender perspectiveA gender perspectivein medicine is in medicine is multidimensionalmultidimensional

……because all players in the because all players in the educational, research and health educational, research and health care process have a gendercare process have a gender

So from the patient’s So from the patient’s perspective…perspective…

……gender perspective in medicine simply gender perspective in medicine simply acknowledges the differential roles that acknowledges the differential roles that masculinity and femininity play in masculinity and femininity play in men’s and women’s healthmen’s and women’s health

Women < 50 yo have 24% higher mortality rate from Women < 50 yo have 24% higher mortality rate from myocardial infarct than men of the same age myocardial infarct than men of the same age (Vaccarino, 1999 NEMJ)(Vaccarino, 1999 NEMJ)

Following emergency room treatment for unstable Following emergency room treatment for unstable angina men have a greater rate of procedures than angina men have a greater rate of procedures than women and suffer worse outcomes (Rogers,2000 JAMA)women and suffer worse outcomes (Rogers,2000 JAMA)

From the providers From the providers perspective…perspective…

……a gender perspective a gender perspective acknowledges the ways in which acknowledges the ways in which the gender of the provider the gender of the provider impacts on the health care eventimpacts on the health care event

In cases of sexual abuse and domestic In cases of sexual abuse and domestic violence, victims are far less likely to present violence, victims are far less likely to present to a doctor of the same gender as the to a doctor of the same gender as the perpetratorperpetrator

From an educational From an educational perspective…perspective…

……identifies the gendered nature of identifies the gendered nature of medical education/texts/teaching medical education/texts/teaching stylesstyles

Women underrepersented in nonreporductive Women underrepersented in nonreporductive illustrations in anatomy and physical illustrations in anatomy and physical diagnosis teaching texts (Mendelsohn, 1994 diagnosis teaching texts (Mendelsohn, 1994 JAMA)JAMA)

Normal GFR [Female GFR] (RACGP)Normal GFR [Female GFR] (RACGP)

Outline of Outline of PresentationPresentation WhatWhat Why botherWhy bother WhoWho What & HowWhat & How Costs & BenefitsCosts & Benefits

But why should we But why should we teach about teach about difference?difference? more or less you are either one or more or less you are either one or

the other on the basis of the other on the basis of biological differencebiological difference

Difference has profound Difference has profound consequences for clinical practiceconsequences for clinical practice

Gender-blindness inGender-blindness inmedical researchmedical research 2/3 of all pharmaceuticals used to treat both 2/3 of all pharmaceuticals used to treat both

men and women have only been tested in men and women have only been tested in menmen

2/3 of all diseases that affect men and 2/3 of all diseases that affect men and women have only been researched in menwomen have only been researched in men

women have only made up 7% of all cardiac women have only made up 7% of all cardiac research subjectsresearch subjects

1 in 3 women die of heart disease in Australia1 in 3 women die of heart disease in Australia

Why is it ‘gender Why is it ‘gender blind’?blind’?

more developed medical research systems in more developed medical research systems in countries with white populations of European genetic countries with white populations of European genetic originsorigins

greater levels of funding in these countries with white greater levels of funding in these countries with white populations of European genetic originspopulations of European genetic origins

Medical evidence developed from research conducted Medical evidence developed from research conducted in less than 10% of world populationin less than 10% of world population

the teratogenic risk associated with involving women the teratogenic risk associated with involving women in clinical trails while in their reproductive years and in clinical trails while in their reproductive years and potential longer-tem outcomes for offspring potential longer-tem outcomes for offspring

Men use health services at a lower rate

Men experience higher rates cancer

Men die 5 years earlier than women

Men experience higher rates of accidents and injuries, including suicide

Gender differences in healthGender differences in health(slide c/o Rob McLachlan, Andrology Australia)(slide c/o Rob McLachlan, Andrology Australia)

A variety of risk behaviours contribute to A variety of risk behaviours contribute to poorer health statuspoorer health status

Rob’s chief beefsRob’s chief beefs Only one Prof of Andrology in AustraliaOnly one Prof of Andrology in Australia

No specific Australia curricula in No specific Australia curricula in andrology - teaching fragmented andrology - teaching fragmented between urology, internal medicine, between urology, internal medicine, endocrinology and O&Gendocrinology and O&G

Male factor infertility (equal to female Male factor infertility (equal to female factor)factor)

Prostate problems (50%)Prostate problems (50%)

From an evidence based From an evidence based perspective …perspective …

……acknowledges the clinical acknowledges the clinical consequences of gender blind consequences of gender blind medical research and the medical research and the resulting medical evidenceresulting medical evidence

A few examples to followA few examples to follow

Some areas with new Some areas with new evidence of differenceevidence of difference Coronary heart diseaseCoronary heart disease Cardiovascular disease and arrhythmiaCardiovascular disease and arrhythmia Brain differences including number of Brain differences including number of

neurons and plasticityneurons and plasticity Differential addiction timesDifferential addiction times Responses to pain medicationResponses to pain medication Eating and digestionEating and digestion Differential drug metabolismDifferential drug metabolism Differential treatment of dyslipidaemiaDifferential treatment of dyslipidaemia Differential carcinogenic and toxic effects of Differential carcinogenic and toxic effects of

tobacco smoketobacco smoke

……and moreand more

Differential risk of lung cancerDifferential risk of lung cancer Differential HIV viral loads and treatment Differential HIV viral loads and treatment

optionsoptions Depression from a genetic levelDepression from a genetic level Sex hormones and cognitive functionSex hormones and cognitive function Differential dietary treatment for obesityDifferential dietary treatment for obesity Gender differences in pre-pubertal childrenGender differences in pre-pubertal children Differential lifetime medical costsDifferential lifetime medical costs Cataract SurgeryCataract Surgery Stress responses and the sympathetic Stress responses and the sympathetic

nervous systemnervous system

Take home messages…Take home messages…

the process must be evidence based the process must be evidence based and balancedand balanced

men have gender issues toomen have gender issues too the process slow to come to medicine the process slow to come to medicine

but common in government, NGO and but common in government, NGO and trans-national institutions worldwidetrans-national institutions worldwide

parts of the process have been parts of the process have been undertaken at other universities undertaken at other universities medical schoolsmedical schools

Outline of Outline of PresentationPresentation WhatWhat Why Why Who’s Who’s doing itdoing it What & HowWhat & How Costs & BenefitsCosts & Benefits

Who’s doing itWho’s doing it

Medizinische Hochschule Hannover & Medizinische Hochschule Hannover & University of Bristol, School for University of Bristol, School for PolicyPolicy

Lit reviewLit review EU Curriculum auditEU Curriculum audit

EU (13)EU (13) Germany, Austria, Switzerland, Spain Germany, Austria, Switzerland, Spain

Sweden, The NetherlandsSweden, The Netherlands

Mainstreaming Gender Mainstreaming Gender (Women’s Health only)(Women’s Health only)

Canada (5)Canada (5) University of Western OntarioUniversity of Western Ontario McMaster UniversityMcMaster University University of TorontoUniversity of Toronto Queen’s University, University of Queen’s University, University of

OttawaOttawa Northern Ontario Medical SchoolNorthern Ontario Medical School

Teaching Gender as a Teaching Gender as a Women’s Health SubjectWomen’s Health SubjectUSA (4)USA (4) Columbia*Columbia* HarvardHarvard MinnesotaMinnesota CincinnatiCincinnati

Sweden (4)Sweden (4) KarolinskaKarolinska LikopingLikoping UppsalaUppsala LundLund

Columbia*Columbia*

Partnership for Gender-specific Partnership for Gender-specific MedicineMedicine

ResearchResearch PublicationsPublications Free Web-based journalFree Web-based journal

http://www.mmhc.com/jgsm/http://www.mmhc.com/jgsm/

No medical school has done this fully No medical school has done this fully on all levelson all levels

A gender perspective in medicine A gender perspective in medicine acknowledges the role that difference acknowledges the role that difference on the basis of sex or gender plays in on the basis of sex or gender plays in all aspects of medical educational, all aspects of medical educational, medical research and clinical practice.medical research and clinical practice.

To be done well this process should To be done well this process should follow a development process similar follow a development process similar to that successfully conducted within to that successfully conducted within UN agencies since 1998UN agencies since 1998

Outline of Outline of PresentationPresentation WhatWhat Why Why WhoWho WhatWhat do we want to achievedo we want to achieve & &

How How do we do itdo we do it Costs & BenefitsCosts & Benefits

What are we trying to What are we trying to achieve with gender achieve with gender mainstreaming in the mainstreaming in the curriculum at Monash?curriculum at Monash? Medical curriculum that reflects evidence of Medical curriculum that reflects evidence of

difference where it existsdifference where it exists

The evidence clearly points to the need for The evidence clearly points to the need for multidimensional mainstreaming of a gender multidimensional mainstreaming of a gender perspective with the goal of achieving perspective with the goal of achieving improved clinical competence in our graduatesimproved clinical competence in our graduates

That is what we have commenced through the That is what we have commenced through the activities of the gender working partyactivities of the gender working party

How are we going How are we going about itabout it Raising awareness of the evidence and Raising awareness of the evidence and

the needthe need Building alliances in the ThemesBuilding alliances in the Themes Representations on Case Development Representations on Case Development

CommitteesCommittees Case Writing with evidence of difference Case Writing with evidence of difference

where it existswhere it exists Contributing evidence for other Case Contributing evidence for other Case

WritersWriters Offering training for staff and facultyOffering training for staff and faculty

Outline of Outline of PresentationPresentation WhatWhat Why Why WhoWho What & HowWhat & How Costs & BenefitsCosts & Benefits

CostsCosts

TimeTime MoneyMoney Need to change cant be difficult Need to change cant be difficult

to graspto grasp Diplomacy requiredDiplomacy required

BenefitsBenefits

Truly evidence based curriculumTruly evidence based curriculum Improved clinical practicesImproved clinical practices Improved outcomes for patientsImproved outcomes for patients More competent graduatesMore competent graduates More informed staffMore informed staff International best practice (our International best practice (our

website is already a resource for website is already a resource for gender teaching worldwide)gender teaching worldwide)