Mainstreaming a Gender Perspective into the Medical Curriculum: Why Bother? Ann-Maree Nobelius Faculty of Medicine, Nursing and Health Sciences Monash University Australia Monash Centre for Medical and Health Sciences Education Seminar Series, 17 th June th June 2003

Ann-Maree Nobelius Monash graduate, Physiology and Pharmacology & Masters in Reproductive Sciences Monash graduate, Physiology and Pharmacology & Masters in Reproductive Sciences medical research background medical research background further studies in sociological research methodology particularly gender studies further studies in sociological research methodology particularly gender studies fieldwork for PhD in Public Health on AIDS in Uganda with UK MRC fieldwork for PhD in Public Health on AIDS in Uganda with UK MRC Employed by School of Rural Health to report on Gender Issues in Rural Medical Practice Project Employed by School of Rural Health to report on Gender Issues in Rural Medical Practice Project Project Officer for Gender Working Party with goal of mainstreaming a gender perspective into entire curriculum Project Officer for Gender Working Party with goal of mainstreaming a gender perspective into entire curriculum

Outline of Presentation What is gender mainstreaming? What is gender mainstreaming? Why bother? Why bother? Who is doing it/what has worked what hasn’t? Who is doing it/what has worked what hasn’t? What do we want to achieve & How do we do it? What do we want to achieve & How do we do it? Costs & Benefits Costs & Benefits

Definitions What is the difference between sex and gender? Sex = male and female Sex = male and female Gender = masculine and feminine Gender = masculine and feminine

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

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

It’s culturally defined ‘man’ = male + masculine social role a real ‘man’, ‘masculine’ or ‘manly’ ‘woman’ = female + feminine social role a real ‘woman’, ‘feminine’ or ‘womanly’

Misunderstandings… ‘gender’ does not mean sex, female or feminism ‘gender’ does not mean sex, female or feminism ‘a gender perspective in medicine’ is not a euphemism for women’s health, feminism or for men needing to ‘get in touch with their feminine side’ ‘a gender perspective in medicine’ is not a euphemism for women’s health, feminism or for men needing to ‘get in touch with their feminine side’ at times impossible to differentiate the biological from the social determinants of health; convention dictates the use of ‘gender’ rather than ‘sex’ in those cases at times impossible to differentiate the biological from the social determinants of health; convention dictates the use of ‘gender’ rather than ‘sex’ in those cases misuse of terms is widespread (we use WHO and UN definitions) misuse of terms is widespread (we use WHO and UN definitions) MEN HAVE GENDER TOO MEN HAVE GENDER TOO

A gender perspective in medicine is multidimensional …because all players in the educational, research and health care process have a gender

So from the patient’s perspective… …gender perspective in medicine simply acknowledges the differential roles that masculinity and femininity play in men’s and women’s health Women < 50 yo have 24% higher mortality rate from myocardial infarct than men of the same age (Vaccarino, 1999 NEMJ) Women < 50 yo have 24% higher mortality rate from myocardial infarct than men of the same age (Vaccarino, 1999 NEMJ) Following emergency room treatment for unstable angina men have a greater rate of procedures than women and suffer worse outcomes (Rogers,2000 JAMA) Following emergency room treatment for unstable angina men have a greater rate of procedures than women and suffer worse outcomes (Rogers,2000 JAMA)

From the providers perspective… …a gender perspective acknowledges the ways in which the gender of the provider impacts on the health care event In cases of sexual abuse and domestic violence, victims are far less likely to present to a doctor of the same gender as the perpetrator In cases of sexual abuse and domestic violence, victims are far less likely to present to a doctor of the same gender as the perpetrator

From an educational perspective… …identifies the gendered nature of medical education/texts/teaching styles Women underrepersented in nonreporductive illustrations in anatomy and physical diagnosis teaching texts (Mendelsohn, 1994 JAMA) Women underrepersented in nonreporductive illustrations in anatomy and physical diagnosis teaching texts (Mendelsohn, 1994 JAMA) Normal GFR [Female GFR] (RACGP) Normal GFR [Female GFR] (RACGP)

Outline of Presentation What What Why bother Why bother Who Who What & How What & How Costs & Benefits Costs & Benefits

But why should we teach about difference? more or less you are either one or the other on the basis of biological difference more or less you are either one or the other on the basis of biological difference Difference has profound consequences for clinical practice Difference has profound consequences for clinical practice

Gender-blindness in medical research 2/3 of all pharmaceuticals used to treat both men and women have only been tested in men 2/3 of all pharmaceuticals used to treat both men and women have only been tested in men 2/3 of all diseases that affect men and women have only been researched in men 2/3 of all diseases that affect men and women have only been researched in men women have only made up 7% of all cardiac research subjects women have only made up 7% of all cardiac research subjects 1 in 3 women die of heart disease in Australia 1 in 3 women die of heart disease in Australia

Why is it ‘gender blind’? more developed medical research systems in countries with white populations of European genetic origins more developed medical research systems in countries with white populations of European genetic origins greater levels of funding in these countries with white populations of European genetic origins greater levels of funding in these countries with white populations of European genetic origins Medical evidence developed from research conducted in less than 10% of world population Medical evidence developed from research conducted in less than 10% of world population the teratogenic risk associated with involving women in clinical trails while in their reproductive years and potential longer-tem outcomes for offspring the teratogenic risk associated with involving women in clinical trails while in their reproductive years and 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 health (slide c/o Rob McLachlan, Andrology Australia) A variety of risk behaviours contribute to poorer health status

Rob’s chief beefs Only one Prof of Andrology in Australia Only one Prof of Andrology in Australia No specific Australia curricula in andrology - teaching fragmented between urology, internal medicine, endocrinology and O&G No specific Australia curricula in andrology - teaching fragmented between urology, internal medicine, endocrinology and O&G Male factor infertility (equal to female factor) Male factor infertility (equal to female factor) Prostate problems (50%) Prostate problems (50%)

From an evidence based perspective … …acknowledges the clinical consequences of gender blind medical research and the resulting medical evidence A few examples to follow A few examples to follow

Some areas with new evidence of difference Coronary heart disease Coronary heart disease Cardiovascular disease and arrhythmia Cardiovascular disease and arrhythmia Brain differences including number of neurons and plasticity Brain differences including number of neurons and plasticity Differential addiction times Differential addiction times Responses to pain medication Responses to pain medication Eating and digestion Eating and digestion Differential drug metabolism Differential drug metabolism Differential treatment of dyslipidaemia Differential treatment of dyslipidaemia Differential carcinogenic and toxic effects of tobacco smoke Differential carcinogenic and toxic effects of tobacco smoke

…and more Differential risk of lung cancer Differential risk of lung cancer Differential HIV viral loads and treatment options Differential HIV viral loads and treatment options Depression from a genetic level Depression from a genetic level Sex hormones and cognitive function Sex hormones and cognitive function Differential dietary treatment for obesity Differential dietary treatment for obesity Gender differences in pre-pubertal children Gender differences in pre-pubertal children Differential lifetime medical costs Differential lifetime medical costs Cataract Surgery Cataract Surgery Stress responses and the sympathetic nervous system Stress responses and the sympathetic nervous system

Take home messages… the process must be evidence based and balanced the process must be evidence based and balanced men have gender issues too men have gender issues too the process slow to come to medicine but common in government, NGO and trans- national institutions worldwide the process slow to come to medicine but common in government, NGO and trans- national institutions worldwide parts of the process have been undertaken at other universities medical schools parts of the process have been undertaken at other universities medical schools

Outline of Presentation What What Why Why Who’s doing it Who’s doing it What & How What & How Costs & Benefits Costs & Benefits

Who’s doing it Medizinische Hochschule Hannover & University of Bristol, School for Policy Lit review Lit review EU Curriculum audit EU Curriculum audit EU (13) Germany, Austria, Switzerland, Spain Sweden, The Netherlands Germany, Austria, Switzerland, Spain Sweden, The Netherlands

Mainstreaming Gender (Women’s Health only) Canada (5) University of Western Ontario University of Western Ontario McMaster University McMaster University University of Toronto University of Toronto Queen’s University, University of Ottawa Queen’s University, University of Ottawa Northern Ontario Medical School Northern Ontario Medical School

Teaching Gender as a Women’s Health Subject USA (4) Columbia* Columbia* Harvard Harvard Minnesota Minnesota Cincinnati Cincinnati Sweden (4) Karolinska Karolinska Likoping Likoping Uppsala Uppsala Lund Lund

Columbia* Partnership for Gender-specific Medicine Research Research Publications Publications Free Web-based journal Free Web-based journalhttp://

No medical school has done this fully on all levels No medical school has done this fully on all levels A gender perspective in medicine acknowledges the role that difference on the basis of sex or gender plays in all aspects of medical educational, medical research and clinical practice. A gender perspective in medicine acknowledges the role that difference on the basis of sex or gender plays in all aspects of medical educational, medical research and clinical practice. To be done well this process should follow a development process similar to that successfully conducted within UN agencies since 1998 To be done well this process should follow a development process similar to that successfully conducted within UN agencies since 1998

Outline of Presentation What What Why Why Who Who What do we want to achieve & How do we do it What do we want to achieve & How do we do it Costs & Benefits Costs & Benefits

What are we trying to achieve with gender mainstreaming in the curriculum at Monash? Medical curriculum that reflects evidence of difference where it exists Medical curriculum that reflects evidence of difference where it exists The evidence clearly points to the need for multidimensional mainstreaming of a gender perspective with the goal of achieving improved clinical competence in our graduates The evidence clearly points to the need for multidimensional mainstreaming of a gender perspective with the goal of achieving improved clinical competence in our graduates That is what we have commenced through the activities of the gender working party That is what we have commenced through the activities of the gender working party

How are we going about it Raising awareness of the evidence and the need Raising awareness of the evidence and the need Building alliances in the Themes Building alliances in the Themes Representations on Case Development Committees Representations on Case Development Committees Case Writing with evidence of difference where it exists Case Writing with evidence of difference where it exists Contributing evidence for other Case Writers Contributing evidence for other Case Writers Offering training for staff and faculty Offering training for staff and faculty

Outline of Presentation What What Why Why Who Who What & How What & How Costs & Benefits Costs & Benefits

Costs Time Time Money Money Need to change cant be difficult to grasp Need to change cant be difficult to grasp Diplomacy required Diplomacy required

Benefits Truly evidence based curriculum Truly evidence based curriculum Improved clinical practices Improved clinical practices Improved outcomes for patients Improved outcomes for patients More competent graduates More competent graduates More informed staff More informed staff International best practice (our website is already a resource for gender teaching worldwide) International best practice (our website is already a resource for gender teaching worldwide)