’In Order to Achieve Equality in Healthcare, We Need to Understand Gender’
The healthcare you receive depends on who you are. Twenty years ago, Katarina Hamberg wrote one of Sweden’s first feminist PhD theses in medicine. Today, she works as a professor and has continued her research in the field of medicine from a gender perspective. ’In order to achieve equality in healthcare, we need to understand gender,’ she says. At the same time, she is concerned about the future of her research field.
Her thesis, presented in 1998, showed that many women who sought medical care for pain symptoms were not taken seriously and often were ridiculed and subjected to domination techniques in their interaction with doctors. Biases in healthcare, or differences in care that are unrelated to medical conditions, remains one of Hamberg’s main research interests. The presence of biases has been studied in a number of medical fields, and all findings point in the same direction.
‘We know that even if two persons have identical medical needs, the treatment they receive may differ depending on their gender, ethnicity, class, age and level of education. Most of the bias research has been carried out in the area of cardiovascular disease, and it shows that men receive better and more expensive treatment and have a higher likelihood of surviving heart attacks,’ says Hamberg.
Overall, the care has become more effective over the years and more patients survive today than in the 1990s, but the gender differential remains.
‘Men receive better care and have higher survival rates than women, just like back in those days’.
Her most recent project deals with the treatment of patients with Parkinson’s disease. Today it is possible to surgically implant a pacemaker in the brain that can then stimulate the damaged area of the brain and improve the patient’s life. However, far more men than women are offered the necessary surgical procedure. Hamberg has carried out interview studies to explore the path to this type of surgery for patients who have had it done.
The study shows that almost all patients who have the surgery done hold positions in society in which they are used to arguing for a particular view or approach. Most of them are well educated, active in a union or in some other way accustomed to discussing and negotiating things with other people. These finding are remarkably similar to those presented in Hamberg’s PhD thesis 20 years ago, and it is overwhelmingly clear that women are still not taken seriously in Swedish healthcare.
‘Overall, more men than women have managed to get the surgery. Many women, too, argued persistently for an opportunity to have the device implanted, but still were not offered the surgery. In many cases, the female patients were not approved for surgery until somebody else, for example an adult child or a partner, contacted the hospital director and sometimes also politicians and the media.’
According to Hamberg, the results of the study are in line with those found in other medical fields – the healthcare is unequal and differs depending on who the patient is and how successful the patient is at arguing for an opportunity to have the surgery done.
Widespread Interest among Medical Students
Hamberg has also studied attitudes to gender issues at medical schools, as well as the work and study environments experienced by medical students. Her research shows that many students are affected by the work environment they encounter during their clinical rotations. The work environment usually differs between male and female students, which often leads to gendered choices of areas of specialisation.
‘When female students decide not to pursue certain areas of specialisation, they have usually experienced a poor work environment in those fields. They avoid work environments characterised by sexism and hierarchies and environments where they have been belittled. Instead, they tend to pursue areas of specialisation where they have felt included and respected during their rotations.’
This pattern became clear in the MeToo campaign launched by Swedish doctors and nurses. They showed that healthcare workers are often harassed by both patients and colleagues, which is a problem that is also evident in Hamberg’s research.
‘Unfortunately, this is a very common experience, and many women in the healthcare sector have adopted strategies to avoid harassment. They may avoid certain situations, and sometimes entire hospital departments or clinics, if they suspect that something might happen there. This is what we hear from the medical students, too. Needless to say, this is energy consuming, leads to stress and limits the career choices of women in particular.’
Unless you pay close attention to these issues, they tend to disappear.
When it comes to students’ attitudes to and interest in gender issues, however, Hamberg says that a lot has happened in the last 20 years.
‘We’re seeing a clear change in society. Many medical students are interested in gender issues and intersectional perspectives. For example, they often request a stronger focus on gender and LGBTQ issues in their education.’
Yet despite the students’ interest, the medical schools are doing a poor job integrating gender issues into their programmes. Umeå University, where Hamberg works, launched a major initiative in 2005 and decided that their programme in medicine was to include compulsory sections on violence, biases, why doctors act biased despite their desire for equality in care and how gender is made and constructed when people interact. Six years later, the Swedish Medical Students Association presented a review of gender at all medical programmes in Sweden. The review showed that several of the new components had been removed from the programme in Umeå. New course coordinators blamed the changes on a need to replace them with more urgent topics. However, Umeå University was still doing a better job with gender integration than many other Swedish medical programmes.
‘Unless you pay close attention to these issues, they tend to disappear. You need to give teachers and programme management teams special assignments. Today, the integration of gender relies on certain individuals with a special interest in gender issues, and when they leave a university, so do the gender components.’
Hamberg believes that besides better integration of gender perspectives in the medical programmes, there is a need for improved reviews to find out what type of gender training works well and how it can be further developed. It is also important to see the direct link to what the healthcare looks like and who receives the right care.
‘New treatments and medicines get most of the attention in medical research, but the individuals who have the problems risk being ignored. When doctors don’t understand how gender, ethnicity, class and other power structures work and interact, it directly affects who will be given a chance to be healed and have a good relationship with his or her doctor,’ says Hamberg.
Concerned about the Future of the Field
When Hamberg wrote here PhD thesis in 1998, gender research was uncommon in the medical field. Medicine was considered gender neutral and interpretive perspectives redundant. In the last 20 years, the use of qualitative methods, such as interview studies, has become more common and accepted in medical research, but medical gender research is still facing major challenges.
‘The gender perspective in medicine is always ranked low, it is considered too interdisciplinary and not interesting enough. Ever since the Swedish Research Council’s special call for gender research grants ended, it has been very difficult to acquire funding for medical research with a gender perspective. Politically, everybody wants equality in Swedish healthcare, but the medical research on how to get there is not prioritised,’ she says.
Without gender research in medicine, there won’t be any teachers with gender expertise at the med schools – at the same time as there is a great need in society and there is widespread interest among the medical students.
According to Hamberg, calls for project proposals in clearly defined fields are very important. Without them, already understudied fields, such as gender-confirming healthcare for trans persons or the consequences of closing maternity wards and entire hospitals in rural areas, may be prevented from evolving, leading to increased inequality in healthcare. She is concerned about the great difficulties in acquiring research funding for several reasons.
‘No new researchers want to pursue research in a field if they know they will have problems getting funded. Without gender research in medicine, there won’t be any teachers with gender expertise at the med schools – at the same time as there is a great need in society and there is widespread interest among the medical students.’
At present, there are fewer younger researchers in medical gender research than 15–20 years ago. There are programmes in medicine where all the students get is some single lecture held by invited researchers from the social sciences or other medical students with a special interest in the topic.
‘I’m seriously concerned about what might happen to the field. Local gender competence, integrated into the research and study programmes, is a cornerstone for successful research and equality in healthcare. It has to be part of our professional expertise,’ says Hamberg.
By Susanna Young Håkansson
Since 1998, the Swedish Secretariat for Gender Research at the University of Gothenburg has been promoting gender research and gender perspectives in research and society. As part of celebrating this, we are writing a series of articles on the development of the field of gender reserach in Sweden, based upon articles previously published in the Magazine Genus, which we released 1998-2013.The at the time newly graduated doctors Katarina Hamberg and Eva Johansson are interviewed in the article “Women with pain are not taken seriously” in Genus No. 1 1999.
Women with Pain Are Not Taken Seriously
Eva Johansson and Katarina Hamberg’s work began when they encountered female patients who experienced pain that could not be explained medically. By applying a gender perspective, they discovered that the women’s social conditions and other circumstances in life affected their health. Their research led to the writing of the first two feminist PhD theses in medicine in Sweden.
Both Johansson and Hamberg work as doctors in Umeå, Sweden. They met in 1989 and their joint research efforts began as a reaction to the frustration they experienced when they came across female patients with pain symptoms but no clear underlying medical conditions.
‘Both of us had started exploring this problem independently of each other and felt that we should do something together,’ says Johansson.
By doing research on the topic, they set out to increase their knowledge and understanding of female patients with pain.
‘We thought that if we follow the women for a few years and let them describe their everyday life, perhaps we can find some new strings to pull and learn more about what was causing their pain,’ says Hamberg.
The research began, and their process was based on a gender perspective centred around gender-related power structures and the women’s situation in life. Last autumn, both Johansson and Hamberg presented their PhD theses at Umeå University. They were titled Beyond Frustration: Understanding Woman with Undefined Musculoskeletal Pain Who Consult Primary Care and Restricted Possibilities Adapted Strategies: A Study in Primary Health Care of Women with Biomedically Undefined Musculoskeletal Pain.
‘They say that there are many levels of the pain. There is not just one answer to the question of what causes the pain. There are several factors involved. For example, their problems can partly be explained by the power structures they have to deal with in life.’
Women Face Greater Demands
Johansson and Hamberg interviewed 20 women. When they analysed the material, they found that the women faced greater demands than the men in their home environment. It also turned out that more than half of the women in the study had experienced violence. In many cases, the perpetrator was an ex or current male partner.
‘The violence says a lot about the conditions that the women have to endure,’ Hamberg points out.
The women who sought medical attention for their pain tended to be from the working class. Many of them had heavy and monotonous jobs and they often had limited opportunities to control their situation at work.
‘Because of the intense demands both in the workplace and at home, the total burdens that these women have to carry are immense,’ says Johansson.
The Power of Doctors
When Johansson and Hamberg met with their patients, they had problems understanding the pains they described. They say that the reason for this is that the interaction between the doctor and the patient is impacted by expectations and the doctor’s power position. The doctor has status, is an expert and is able to write prescriptions.
‘The patients came in to talk about the body, but the body is affected by how the person is doing socially. Many doctors have difficulties seeing the big picture and talking about both the body and the soul,’ says Johansson.
Johansson and Hamberg looked closer at how the women were treated when seeing a doctor and noted that they were often subjected to classical domination strategies. When describing their symptoms, they were ridiculed and dismissed as irrelevant.
‘The women clearly felt like the doctors didn’t take them seriously, and similarly, the women didn’t have much faith in the doctors either.’
Interpretive Perspective Traditionally Not Accepted
Johansson and Hamberg could see similar tendencies in themselves.
‘Despite the fact that as a female doctor you want to make sure you treat your female patients with patience and compassion, it was difficult to respond to them properly,’ says Johansson.
As the first Swedish researchers to present feminist PhD theses in medicine, Johansson and Hamberg have received a lot of attention. Why is gender research so uncommon in the field of medicine?
‘An interpretive perspective has traditionally not been accepted in medicine,’ says Hamberg. ‘You are supposed to be objective and neutral, and there has not been any place for a gender perspective within that framework. It has long been claimed that medicine is gender neutral.’
The two researchers have mostly received positive reactions from the scholarly community, but not everyone has been impressed.
‘There are always critics saying that ”This is not science. Where is the control group? This can’t be serious research. It’s more like art”.’
But Johansson and Hamberg feel that a vast majority are interested in the gender perspective.
‘Maybe we were just right timewise. Maybe we wouldn’t have been as successful had we done it 5 years earlier. After all, when we started, an awareness of gender perspectives had already started to emerge.’
‘All along, we have had a feeling that this is just common sense, but even though we know this, it’s not established practice in medicine,’ says Hamberg.
‘That’s what keeps motivating us.’
Written by Jenny Gustavsson
Published (in Swedish) in Genus issue 1, 1999