Tuesday, 24 December 2019

The Medical Profession is Female

A man and his son are terribly injured in an accident. They are taken to hospital requiring surgery. A surgeon is called, but looks at the boy and says "I can't operate on this boy: he's my son!" How is this possible?

Does this riddle perplex you? If so, you may be demonstrating your innate gender bias, that surgeons ought to be male, and therefore you expect the surgeon to be the boy's father. Of course, the common answer is that the surgeon is the boy's mother (though it's becoming increasingly possible that the boy is the child of a gay couple).

My media feed this week sparked my interest with its announcement that the "Medical Profession is Female", and I followed the link.

Professor Elizabeth Loder is a professor of neurology at Harvard, and the head of research at the British Medical Journal. She writes (my italics):
Loder: Soon, most doctors in the US, the UK, and Europe will be women; this is already the case in many countries (...) The stereotype that doctors are men persists at a time when almost half of physicians are female—and it has been internalised by women physicians like me—so it’s a problem that needs to be fixed. How to do this? It would help to retire “he,” “him,” and “his” as the default pronouns for doctors and make a deliberate switch to “she,” “her,” and “hers.” Pronouns are in flux, and it’s possible that “they,” “them,” and “theirs” will become standard. Until that happens, I have a proposal: when in doubt, and the gender of the doctor is unknown, let’s use female pronouns to send a message and open minds.
Professor Elizabeth Loder
There is no doubt that she is right. Women outnumber men at admission to medical school already, and my own belief is that more than half of all doctors are already women.

Loder's piece was prompted by a paper recently published in the BMJ which shows that female scientists are less likely to use positive terms to describe their research findings compared to male scientists. The men tend to use positive-sounding words like novel, unique, or unprecedented, and papers with this more positive language get cited more often.

Academic papers are usually cited in a way which masks the first name of the authors. They are usually given by their initials only: (Lennon J, McCartney P, Harrison G, Starr R), which makes it pretty hard to infer anyone's gender. I had always considered that this made academic publishing encouragingly gender-neutral, but the BMJ paper shows that there is a measurable male-female difference.

As an amusing aside, those of you who are familiar with British English will know the expression "old Uncle Tom Cobley and all", meaning "everyone imaginable". I was delighted to discover that there are several listings in academic journals where Cobley UT has been listed as a co-author!
Loder: Using female pronouns for doctors would force everyone, on a regular basis, to remember that women can be doctors. Soon the default use of female pronouns will make sense for the same reason we’ve defaulted to male pronouns: it will be the best reflection of reality and the new gender makeup of the physician workforce. Furthermore, in situations where most doctors are male (surgical subspecialties, for example), it’s then even more desirable to use a default pronoun of “she” to expand people’s ideas of who can be a doctor.
I'm already doing this very deliberately in my Quora answers, and at work I am careful to deliberately avoid assuming male pronouns for doctors (instead I tend to use they). The very first post I ever wrote on this blog, back in 2011 (!) was about pronouns, although I must say that the invented, gender-neutral pronouns still grate with me wherever I see them.

What I saw, twenty or more years ago, is that to succeed in medicine, women had to outperform the men. That meant that the few female consultants and professors, that I knew then, tended toward the ferocious spinster archetype. I got the impression these were women who had sacrificed a lot (personal life, family life) to get their positions. Many seemed to me to be bitter and battle-hardened: sick of proving themselves right in front of mansplaining men who were not as good as they were.

Before she was that doctor, she was this doctor.
It was considered acceptable for women to do the “touchy-feely” specialties, such as general practice or psychiatry. But women found it very difficult to succeed in the “tougher, harder” specialties such as surgery (especially orthopaedics). The following quote comes from my favourite dark medical drama, the wonderful Cardiac Arrest:
Just because surgery involves a bit of sewing doesn’t mean it’s any job for a housewife!
I personally witnessed the deliberate, ritualised bullying of a highly capable surgical trainee who had committed two grave sins: being a woman, and having brown skin.

But things have changed, and are still changing. Those battle-hardened spinsters have blazed the trail, and women are streaming into specialties which have previously been off limits. And they no longer need to do battle with the boys, which means they are more relaxed and able to express themselves. Some female surgeons operate with little feminine touches: fabulous pink surgical boots (instead of boring white) or operating spectacles with little sparkly bits glued onto the legs and rims. These sound like little things, almost trivial, but they represent ground which was hard-fought for, inch by inch.

The men are, in general, much more respectful and better-behaved. Some of the older ones have ascended to higher echelons, which means that Medical College councils and presidents still tend to be mostly men. But even here I am hearing new dialogue. The president of my Medical College (a man) announced that, considering all the Annual Scientific Meetings our College has ever held, over 100 keynote speakers have presented, and only six were women. Imagine, he said with genuine sincerity, all the talented speakers we have missed out on. (This year nearly all the keynote speakers were women).

That talented surgical trainee I knew back in the day has made it; she was far too talented not to. But she lost something along the way: her compassion is far less now than it was when I knew her. She too has been battle-hardened.

I remain hopeful that these trends continue, and I remain certain that medicine (and hence patients) will benefit from improved gender balance.

But there is one thing still missing: where are the trans doctors? If, as I suspect, there are just as many transgender doctors as there are in the general population, where are they all? This is a subject I intend to explore more fully in a later post, because I've been doing a lot of looking. Meanwhile, if you have a story or viewpoint to share, please leave a comment.

Friday, 6 December 2019

Shifting Sands

Although it's over a year since its release, I came across this amazing publication, and I wanted to give it wider recognition.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is the medical college responsible for setting training standards for doctors specialising in the field of Obstetrics and Gynaecology in Australasia. So it's a very large, prestigious, academic organisation.

As most medical colleges do, it publishes a flagship academic journal; but also a more informal publication, O&G Magazine, which I admit I had never come across until I saw a pile of them lying in my hospital. The top one caught my eye, because it was colourful, and because it looked like Tetris (which is one of my favourite games). When I looked closer, I saw that the theme of this particular issue was "LGBTQIA", so I picked it up to have a read. I was immediately captivated. Best of all, the entire issue is available free online here.

Let's start with the editorial, from incoming RANZCOG President Dr Vijay Roach:
Roach: This issue of O&G Magazine addresses an important aspect of social, cultural and clinical life in Australia and New Zealand. Members of the LGBTI community have experienced a long history of marginalisation and discrimination, often to the detriment of their physical and mental healthcare. While the College acknowledges a diversity of opinion in the community and among our members on many issues, on one thing we are united: RANZCOG believes that every person, independent of their sexual orientation, has the right to high-quality medical care. 
In 2017, the RANZCOG Board issued a statement on same-sex marriage which read, in part '… the Board affirms its support for marriage equality and calls upon the Australian Parliament to ensure equal opportunity for lesbian, gay, bisexual, transgender and intersex (LGBTI) Australians in same-sex relationships and their families …' I was proud to be a member of that Board and grateful to then-President Prof Steve Robson for his leadership.
In this issue, the O&G Magazine editors have assembled a diverse series of articles relevant to the care of the LGBTI community. It is compelling reading and relevant to everyone’s practice.
The list of articles is impressive:
Fertility options for gender and sexually diverse people (Bronwyn Devine)
Rainbow IVF (Sarah van der Wal)
Gender dysphoria (Simone Buzwell)
Gender dysphoria: a paediatric perspective (Noel Friesen)
Fertility preservation in the transgender child and adolescent (Tamara Hunter)
Intersex: variations in sex characteristics (Jennifer Beale)
What do intersex people need from doctors? (Morgan Carpenter)
Hormonal treatment of the transgender adult (Rosemary Jones)
Surgery for transgender individuals (Charlotte Elder)
LGBTQIA gynaecological screening (Kimberley Ivory)
Takatāpui (Elizabeth Kerekere)
Tekwabi Giz National LGBTI Health Alliance (Rebecca Johnson)
Glass closets and the hidden curriculum of medical school (Amy Coopes)
Australia's queer history (Robert French)
I read these articles with two sets of eyes. The first were my medical eyes: was this the sort of thing that, as a doctor, would be helpful for me to read? The answer is clearly yes. The second were my transgender eyes: was this the sort of thing that, as a trans person myself, I would want doctors to read and know? The answer is also a clear yes. There is no doubt that transgender people are becoming more and more visible; their care has been, in the main, not that great; most doctors have very little training in care of transgender people, and reliable resources for doctors to draw upon are few.

The various authors all have special expertise and interest in their various fields, which is commendable. But it's the range of subjects which strikes me as particularly noteworthy. I've sometimes felt that the T is kind of tacked on to the end of LGB as an afterthought. But here we are, right in the middle, with articles dealing with not just hormones and surgery but issues like fertility and childhood and emotional wellbeing. Amazing.

I was pleased to note that the tone of all the articles was spot on, from the acceptance of the individuals, to recognition that care matters but is frequently lacking, to pragmatic information and guidance for practitioners.
There are several points which are very much worth making about a publication of this type.

(1) First, it's great that a major medical college is being so overtly inclusive. That alone is magnificent. RANZCOG is setting an example for others to follow. There has been lots of Twitter support for the issue.

(2) Second, most medical colleges publish guidelines for the care of patients with X condition. What strikes me about this one is a subtle but powerful shift in tone: not "this is what these patients are like" but "this is us, and that's OK". As Amy Coopes points out in her article, there is still great stigma in medicine if you are gay or non-binary. So a publication like this is extremely affirming. As a transgender person with a medical degree myself, I immediately wanted to reach out and make contact, so I wrote to RANZCOG and congratulated them on their magazine (and I’m not the only one: there is a very heartfelt response from a gay obstetrician in the following issue here).

(3) I wouldn't have necessarily expected O&G to be the specialty which would deal with the care of transwomen. Post-transition, care could potentially be complex, since O&G specialists are more used to the care of people with a uterus and vagina than a prostate gland. But this issue seems to be saying to its readers: don't panic, you can do it! It's started me discussing these issues with some of my colleagues much more openly than previously.

Whether you are medical or not, it's well worth having a browse through this magazine. If you're aware of any other medical organisations being explicitly rainbow-inclusive, please let me know.