Sexism and Biases in Medicine
An overview of the problems with the way modern day medicine is taught and practiced
Sexism exists in medicine - and a lot of us medical students can vouch for that. It’s often directed at us - women in the field are often called “nurse” instead of doctor (or sometimes “lady doctor”), the orthopaedics department is usually full of men, the opposite goes for gynaecology - but more often than not, given that doctors are the authority figures in this setting, we are the ones imposing most the sexism.
A lot of it isn’t necessarily intentional. We might not consider ourselves sexist, but long-term conditioning often makes it an inherent, unsaid bias in all of us. Furthermore, as budding healthcare workers, we’re often taught things in our classes and clinics that are based on sexist stereotypes - for example, examining a female’s ‘virginal’ status in managing rape victims; or that women are more likely to be diagnosed with depression than their male counterparts exhibiting the same symptoms, because we’re taught that women are more commonly affected by such mental disorders.
Now this might get tricky - biology inherently differentiates between sexes. Females are more likely to get SLE (or other similar auto-immune conditions), and males are more likely to have red-green colour blindness. Taking the example of depression quoted earlier - women are, indeed, more likely to get anxiety, depression, PTSD, anorexia, etc., and therefore one could conclude that maybe that’s why, for the same set of symptoms, we are more likely to medicate females than males. It’s also worth noting that while some of these differences might be biological (eg, females are at higher risk for alcohol-associated bodily damage), others are social (eg, men are more likely to indulge in alcoholism).
But this doesn’t really change the fact that a lot of the sexism in healthcare is -
1. Damaging to the patients who face it, and 2. Unnecessary and avoidable. For those of us who intend to practice healthcare in the future, or do so now, it is imperative that we consciously tackle the sexism our peers and us are responsible for.
Most of this sexism is borne in an early stage of our approach to patient care - i.e, history taking. History taking is where we make our preliminary judgments - who is the patient, what are their chief complaints, what differential diagnoses suit their presentation? The process of history taking essentially demands that we profile the patient with the filters we have. So how do we make sure our profiling is accurate but fair, without resorting to deep-rooted stigmas?
Leaving All Assumptions at the Door
This is necessary not only for a fair medical history, but also to make sure the patient is comfortable.
For starters, we generally note down a patients sex based on a visual assessment, but this might not always give us the correct results. It is important to remember here that sex, gender identity, and gender expression are all different things, and may not conventionally align the way we expect.
At the same time, some patients might take offence to you asking you what their gender it is. It comes down to a personal assessment of what the situation demands - but when in doubt, its always better to ask. A good tip is to always ask a neutral question (“What gender do you identify as?”) rather than leading questions (“Are you a male?”).
Beyond this, there are also other assumptions we need to consciously omit for the sake of a more rounded history - for example, especially in India and in it’s public hospitals - we tend to assume that all unmarried women are virgins, and therefore might not ask for a sexual history, which may lead to us excluding an important parameter of our diagnosis. On the flip side, when assessing a sex worker, we might tend to always assume her symptoms to be suggestive of a sexual aetiology, or due to an STI, when they might not be. While certain questions based on assumptions can help streamline our approach towards cases, missing out on the key step of asking an open ended question to confirm your approach may often lead to an uncomfortable interaction. In this way our preconceived biases may also end up hindering our quest to reach the correct diagnosis.
Not Letting Your Prejudices Colour The Facts
One of the defining features of a doctor-patient relationship is that it involves the patient confiding in their doctor - and it is important we maintain that trust, respect their choices, and aren’t dismissive about what they tell us.
A common issue is that transgender patients are often made to feel ghettoised or unwelcome - not just because their gender expression choices are looked down upon and judged, but also because doctors are quick to blame their symptoms on the presumption of ‘promiscuous sexual behaviour’ and their “choice to be this way”. This probably stems from the significant lack of conversations within the health-care field (that is dominated by cis-folks) about the bodies and health of trans-people.
Prejudice, however, is pervasive and clouds our objectivity in medical cases - and the repercussions are pretty severe. Consider the fact that doctors are less likely to take women’s complaints seriously, because women are considered ‘hysterical’, extra sensitive and emotional. The statistics as they stand are pretty bad - 50% of critically ill women are less likely to receive life saving medical interventions than men, and women’s pain symptoms are taken less seriously than a man’s, because a woman’s pain is often dismissed as psychological instead of physical.
In technical terms, this is called medical gaslighting. To be clear, gaslighting is the repeated denial of someone’s reality in an attempt to invalidate or dismiss them. This is a form of emotional abuse. When a medical professional leads a person to question their sanity, it can be just as traumatic and abusive; and because it involves the dismissal of people’s bodies — more often, ones that aren’t male, cisgender, heterosexual, or abled — the effects are physical, too.
When doctors mistakenly conclude that a person’s symptoms are ‘all in their head,’ they delay a correct physical diagnosis. This is especially crucial for patients with rare diseases, who already wait an average of 4.8 years to be diagnosed.
Other impacts of this subtle medical gaslighting includes -
Women being more likely to have their pain described as “emotional” or “psychogenic,” and therefore are more often given sedatives instead of pain medications.
Patients of lower caste experience bias and are examined less thoroughly than their upper caste counterparts, which may explain why many wait longer before even seeking out care.
And patients with more weight are often unfairly viewed as lazy and noncompliant.
3. Not Letting the Facts Affect Your Service
Another thing we might notice is that doctors sometimes project their own morals and values onto their patients. This not only influences how healthcare professionals provide treatment (i.e., refusing to provide abortions because they’re against the practice), but also affects our service at an early stage like history taking.
We might disagree with a patient’s choices, but it is still our professional duty to provide them with the best standard of service that we can. Often helping a patient is refuted at an early stage - for example, if a woman does not use contraception, and chooses to have multiple children in quick succession, an advocate of family planning might not agree with her decisions and might coerce or force her to use contraceptive devices. The words we end up using are “Aap log sochte nahi ho, sirf pregnant ho kar yaha aa jate ho”. The doctor might inaccurately blame her medical condition(s) on her choice to have many children, or focus on berating her for her choices rather than solving the medical issue she is presenting with. If a rape victim confides in the doctor that she was not a virgin, or was raped when under the influence, the doctor might be quick to hold her responsible for the crime and might take an unfavourable history. Apart from these examples, there are also moments where we don’t hesitate to pass snarky remarks about people’s lifestyle choices.
The problem in the first issue presented above isn’t whether the patient should’ve resorted to family plan or not, it’s that the choices she makes with her body are not for us to pass judgements on and should not affect our medical approach and objectivity. We don’t even know the whole story, or why a patient makes the choices they make. There are so many factors that go into that kind of decision making - knowledge, awareness, ability to negotiate on contraception, consent - just to name a few.
At the end of the day, medicine is not an exact and absolute science - it’s more subjective than mathematical, and while some generalizations do help us narrow down the disease and its aetiology - it really is so much more than that. Eventually, it comes down to understanding whether the generalizations and assumptions we make are fair or not - whether they’re aiding our diagnosis or hindering it, and whether they’re rooted in facts or patriarchal judgement that we’ve been passing down over the years. We must constantly question and review the things we’re taught and learn that medicine doesn’t deal in absolutes either - every rule or trend has exceptions. It’s the least we can do to be consciously open minded and considerate. It’s the least we can do to be decent doctors.