Women in Medicine

Women in medicine have had equal pay for many years, since long before it became a widely voiced political demand, and over the last decade-and-a-half the proportion of women admitted to medical school has increased to about half. (A large part of this chapter in based upon an article which I co-authored with Dr Judith Gray. S.J. Watkins and J. Gray, ‘Sexism in Medicine’ first appeared in Medical World in 1981 and was later republished by ASTMS in Women and Medicine – an MPU Policy Document. It was my intention to ask Judith to approve the changes and additions which I have made to that article and invite her to be named as co-author of this chapter. Her tragically early death made this impossible.) On the face of it this represents a substantial victory over discrimination. Certainly women in medicine are far ahead of their sisters in many other professions and occupations in their acceptance and even in their success in making arrangements to cope with their special problems. However, problems remain.

Personal Psychological Pressures

On Women

Women medical students are subjected to particular psychological pressures. On the one hand, like all young women, they are expected to be flirtatious and feminine, and on the other hand, such behaviour will be regarded as evidence of a lack of professionalism. If they do behave as expected they will be labelled ‘unprofessional’ and if they do not, they will be despised as ‘career women’.

Academic success is not always regarded as desirable for women. In an American experiment two groups were asked to complete the sentences ‘John came top of his class at the end

of his first year at medical school’ and ‘Ann came top of her class at the end of her first year at medical school’. John was seen as successful with a good sex-life and a brilliant career; Ann was less fortunate – she was seen as despised, dateless, a grind and not very successful.

After qualification the same no-win situation continues. Either a woman foregoes marriage and child-care and accepts the consequent social stigma, or she combines child-bearing with a career and is condemned for being a bad mother, or she gives up work and is condemned for wasting the investment in her education.

The theory of maternal deprivation – the idea that a child requires the constant presence of a single human female, that female to be the mother, is based upon no scientific evidence whatsoever (certainly not after the first year or so of life). Indeed, there is evidence that the development of intelligence and creativity in children is positively associated with being brought up in families where sex-roles are less differential. Since individualised child rearing is of relatively recent social evolutionary development, the theory that it provides substantial biological benefit is strange. Yet this absurd theory, totally lacking scientific evidence, is widely accepted in our society, largely because it legitimates the political objective of keeping women in their place, and justifies the disgraceful lack of child-care facilities.

A women need not therefore feel guilty about combining child-bearing with a career. But nor should she feel guilty if she decides that she does not want to take a few years off her career in order to bring up her child for the first few years of its life. The ‘loss of investment’ will be no greater than that involved in the greater liability of men to be disabled, to die early or to emigrate. Indeed, on economic grounds there is a much greater case for banning men from medical schools than for banning women, for the ‘loss of investment’ from women is based upon social arrangements, which can fairly easily be changed, whereas the ‘loss of investment’ from men is much more deep-rooted. ‘We cannot train men as consultant surgeons in case they have heart attacks just when they are starting to pay off the investment’ would be as logical as ‘we cannot train women in case they marry and have children’, but for some reason does not seem to have caught on quite so much in the minds of appointment committees.

Women faced with these pressures are forced into a choice which men do not have to make – children or career. To be successful they are expected to become ‘honorary men’, to adopt the ambitious, success-oriented, instrumental psycho­logical orientation of men. Yet this is totally inappropriate in medicine. For the psychological orientation which our society culturally imposes on women – a nurturing caring orientation – is exactly the value system which is needed of a good doctor. The fact that generations of men have found it possible to pursue their medical career as a route to status and power should not obscure the fact that a caring orientation should be the orientation of doctors.

On Men

In discussing the personal psychological pressures on women we must not overlook similar pressures on men. Men are under tremendous social pressure to base a successful career upon the exploitation of other human beings – their wives. And men who consciously try to reject those pressures and try to enter a symmetrical, mutually-supportive relationship in which roles are shared, enter what almost amounts to a deviant sexual role. Moreover, of all sexual roles, that of heterosexual non-sexist male is the loneliest and the least supported – only in recent years has ‘Men Against Sexism’ come into being. Yet men need support if they are to break out of the emotionally crippling, instrumental psychological orientation, and lack of preparation for child-care and housework, which male sex-role differentation frequently imposes upon them.

Once a man has decided that he is not going to base his life upon the exploitation of a woman, he is faced with many of the same agonising dilemmas that face women. The problems of a woman trying to combine a career with child-care are bad enough, but the problems of a man trying to do the same are even worse. His behaviour is even less acceptable than hers, so that his difficulties are intrinsically greater. Her demands are at least seen as legitimate attempts to pursue her ‘proper’ social role without abandoning her profession, whilst his are seen as the abandonment of his career for a social role that is not properly his. She has the support of a long tradition of feminism, he has the support only of a weak and new ‘Men Against Sexism’ movement. She is inspired by the knowledge that she is fighting for her rights, he is inspired only by the knowledge that he is doing what is right. (It could, of course, be argued that men are fighting for their own right to emotional expression.)

It is particularly important to support non-sexist men in the conflicts that role-sharing brings, if role-sharing is indeed to become the normal mode of behaviour in our society.

Career Choice

Doctors find it easier to combine domestic commitments with careers in the shortage specialties – geriatrics, community medicine, psychiatry, mental handicap, pathology, radiology, rehabilitation, anaesthetics and so on. Difficulties are greatest in the prestige specialties of surgery, general medicine or obstetrics and gynaecology. It is therefore easier for doctors to choose the specialty in which it will be easiest for them to pursue their career as they want.

It would be wrong to dissuade anyone from choosing a career in the Cinderella specialties. Geriatrics, psychiatry, mental handicap, community medicine, rheumatology and rehabilitation are vitally important and should reject the medical profession’s status system which has labelled them as second class. If doctors want to enter those specialties they should do so.

But feminists and their sympathisers would certainly argue that women who genuinely want to become surgeons or physicians, not because they are of high status, but because that is the kind of work they want to do, should not be put off by the discrimination that they will face. They should fight that discrimination whilst appreciating from the outset that they are going to be taking the system on and will need to fight.

A further special problem faces doctors in obstetrics and gynaecology: the specialty is permeated by attitudes to women which most feminists find unacceptable. Again, doctors must decide whether to fight those attitudes or to succumb to pressures.

Community-health work – family planning, well-baby clinics, etc. – is one area where many doctors have found it possible to combine work (the present status of jobs in this area is such that it can hardly be called a career) with domestic commitments.

Many doctors have accepted sub-consultant grades, such as Medical Assistant or Clinical Assistant posts, in order to avoid the hassle of climbing the ladder.

Here the left faces a conflict. On the one hand it opposes the status system that labels such posts as second rate. It believes that there is a place for a sub-consultant grade, that there should be proper careers in the community health services and more status for the Cinderella specialties. So it does not wish to dissuade women from entering these fields of work. But it does wish to prevent their doing so simply because of discrimination reinforcing both sexism and the status system at the same time by choosing this work as a declared ‘soft option’.

So the MPU gives the following advice to a doctor wishing to combine a career with domestic commitments:

Decide what you want to do and fight for your right to do it. Do not be influenced by the problems you will face in prestige specialties, but don’t be influenced either by the prestige. Many of the ‘escape routes’ are, or should be, routes to professionally satisfying work which doctors should want to do and you should not be distracted from them by the glittering prestige of high technology (hospitals are not meant to be adventure playgrounds for doctors). But neither should you accept that only those areas of work are open to you — by all means enter them because you want to, but do not enter them because of the pressures of medical sexism.

Either way, anti-sexist doctors face a fight. Whether it is the fight to raise the status of the neglected groups in the profession, or the fight against sexism in the prestige specialties, you are going to have to fight for your professional self-respect.

A much more complete case for adopting this position can be found in the book Women and Medicine by Joyce Leeson and Judith Gray, which also reviews the position of other women health workers, the history of women in medicine, the  women’s health movement and the way that issues of women and health have been dealt with by trade unions, the labour movement and the women’s movement. ( Leeson and J. Gray, Women and Medicine, London 1978.)

It would be foolish to attempt to reproduce within a single chapter the carefully marshalled facts and arguments of that book.

It is intriguing to consider the full implications of the suggestion that the nurturative psychological orientation imposed on women means that women make better doctors. Hilary Burrage has pointed out, in her pioneering study of women scientists, that amongst 1973 graduates 25 per cent of doctors were women but only 7 per cent of scientists, despite the higher academic standards required for entry to medical school, and that a significant number of women scientists had turned to the natural sciences only after abandoning an intention to enter the medical or paramedical professions. (H.F. Burrage, ‘Women Scientists’, M.Sc. Thesis, University of Salford, 1973.)  Leeson and Gray also point out that in the socialist countries the preference of women for medicine rather than science is still seen, since although there are more women scientists than in the West there are even more women doctors.

There have been suggestions that the fact that half of the medical school entry is now female may conceal discrimina­tion against women to prevent their becoming the majority, although it is unclear how well based such suggestions are.

Effects of Discrimination and Social Pressure

The key problems faced by women doctors after qualification are discrimination in senior appointments in prestige specialties and the problem of combining a career with domestic commitments.

These two problems together create a situation in which there are far fewer women in senior posts in the medical profession than there are in the profession at large, and this is especially obvious m the prestige specialties.

Thus, as LeesOn and Gray point out, in 1974 women constituted more than one third of pre-registration house officers, but only one fifth of Registrars and Senior Registrars, and less than one tenth of consultants.

Although this could be partly explained by a ‘cohort effect’ in which the increased proportion of women in recent years’ medical school intakes has only reached the more junior grades as yet, this could not be the whole story, since there were also differences in the proportion of women in particular career grades dependent on their status.

Women constituted 5.5 per cent of consultants in prestige specialties, but 12.6 per cent of consultants in shortage specialties and more than one third of medical assistants. These posts would all be filled from the same ‘cohorts’ of graduates. It must also be borne in mind that in the ‘cohorts’ of graduates from which these career grades would have been filled, women were discriminated against in medical school entry and therefore those women who were admitted were both more committed and more able than men admitted at the same time. Nor can the distribution of women be explained by a reluctance to appoint part-time prestige specialty consultants since these are the very posts in which a high proportion of consultants work part-time for the purpose of private practice.

This statistical evidence is borne out by considerable anecdotal evidence of discrimination. One consultant surgeon was heard to say that he thought women could not stand up to the strain of standing in an operating theatre all day -presumably he had managed to find a male theatre sister and an all-male nursing staff! These anecdotes are in turn borne out by the folk knowledge of the medical profession which takes it for granted that racial, sexual and political discrimination occurs.

To cope with the problem of discrimination the MPU has suggested an Equal Opportunities Subcommittee of the Central Manpower Committee. This subcommittee would deal with racial and political discrimination as well as sexual discrimination and it would have power to investigate individual complaints that a particular doctor was not making the career progress that would have been expected (rather than just that she or he had been discriminated against in a particular appointment, which is very difficult to prove) and also to investigate statistical evidence of discrimination against particular groups. The subcommittee would have power to appoint observers to Appointments Committee, and would also have power to direct the Secretary of State to find a particular doctor, who had been shown to have suffered discrimination, a job of a particular type. The subcommittee would also run a special scheme for junior hospital doctor appointments for doctors who needed to be geographically mobile in accordance with the requirements of their spouse (particularly important for doctors married to other doctors).

As might be expected this proposal has made no headway, although a resolution supporting the idea was approved by the BMA Junior Members’ Forum in 1983.

More attention has been given to the problem of domestic commitments.

A study of the effect of domestic commitments on women doctors was carried out by the MPU as long ago as 1962-63. (This was published in 1966 by the Office of Health Economics. There was some acrimony over the publication since one of its authors, Patricia Elliott, a former General Secretary of the MPU, was amongst those who left the union in the schism of 1965, and wished to use some of the material in the publication then being planned by the Medical Women’s Federation.) This study elicited information from more than 8,000 women doctors. Of these 47 per cent were working full-time, 32 per cent part-time, and 19 per cent were not working at all. 90 per cent of those over the age of 45 were working and those who were not at work were mainly married women with children under five. Only one fifth of women with young children and one third of women with older children were working full-time. The majority of the non-employed women wanted work, especially part-time work, but found none available in their locality. The MPU argued that this meant there was a special need to make arrangements for women to combine a career with domestic commitments.

Some special arrangements were made, including the Doctors’ Retainer Scheme which allowed doctors to keep a small number of clinical sessions whilst looking after a family, and some special arrangements for reintroducing women into medicine when the time came to return to work. These arrangements fell far short of the needs of women, and were oriented around the assumption that women would give up work for a time.

In 1979 the MPU proposed a successful resolution at the Hospital Junior Staff Conference calling for part-time training in all specialtiqp, creche facilities in all hospitals, more flexible maternity leave arrangements and paternity leave. The sections on creche facilities and paternity leave were repudiated by the BMA, but the HJSC, after an intensive MPU campaign, exercised its autonomy and stood by its conference.

Although lip-service is paid to the need for part-time training (the Royal Colleges have agreed to recognise it, and the BMA has set up a job-sharing register) the supply of part-time jobs remains inadequate, and only one job-sharing appointment had been made at Senior Registrar grade by July 1985, although surprisingly this was a prestigious university-linked appointment.

It has also been necessary to fight a number of rearguard actions to preserve even the paper commitment.

Women’s Organisations in Medicine

There are two main women’s organisations in medicine, the Medical Women’s Federation (MWF) and Women in Medicine. There is also a smaller organisation, the Women Doctors’ Action Group.

The MWF is a long-established organisation and the traditional voice of medical women, whilst Women in Medicine is a new organisation that is explicitly feminist.

The antecedents of the MWF were a number of Associations of Registered Medical Women, of which the first was the London Association, founded in 1879. By 1911 seven( such regional organisations existed. Between 1911 and 1917 the need for a single representative body of medical women began to be discussed by all these associations and on 1 February 1917 the seven organisations came together to form a national federation.

From its establishment the Federation formed a close relationship with the BMA and was given representation on the Maternity and Child Welfare Committee, the Parlia­mentary Elections Committee and the Insurance Acts Committee (a seat which it retains to this day on the successor of the IAC, the General Medical Services Committee). Today the MWF rents offices in BMA House.

In 1919 the MWF and the American Medical Women’s Association founded the Medical Women’s International Association, which was responsible for founding medical women’s associations in a number of other countries.

At first the MWF was concerned with fighting for equality of pay and opportunity (equal pay was not universally achieved until it was conceded by the armed forces during the Second World War). By 1959 the Federation felt that ‘there was now no real difficulty about the employment of single women who worked full-time,’ and it turned its attention to part-time work. In 1963 and 1964 it carried out surveys which it published in 1966. The MWF has established a career-counselling service for its members, and offers practical help in finding part-time work. The MWF has successfully fielded candidates for the General Medical Council in the 1979 and 1984 elections.

The broad base of the MWF and its links with the estab­lishment have never detracted from its willingness to speak out on the problems of women but it has not taken explicitly feminist stances. Over the last decade two attempts have been made to set up more radical organisations. The first of these, the Women Doctors’ Action Group (originally the Married Women Doctors’ Action Group) attracted only limited sup­port, but the explicitly feminist organisation Women in Medi­cine has been successful in rapidly carving out a niche for itself. It has, however, declined to involve itself in medical politics because this would involve the adoption of formal organisation and policies which would divide the organisation. The task of holding the medico-political line for women has therefore been left to the MPU and the MWF. However the influence of Women in Medicine is still visible through its influence on the ideas of those of its members who are active in medical politics, and through its support for them.

The BMA has refused to make any special arrangements for representation of women within its structure, except for the MWF seat on the GMSC. The MPU, however, has set up a Women’s Committee within its campaign structure and has also encouraged women to participate in union affairs, with the result that the representation of women on MPU Council has increased to a point where it exceeds the proportion of women in the profession.

Women’s Health

The key demands of the women’s health movement are fertility control, well-women clinics and a less patronising doctor/patient relationship.

The last of these has been discussed in Chapter Nine and clashes with doctors’ perceptions of their role in that relationship.

The issue of fertility control raises two important issues -legalised abortion and good family-planning services.

The medical profession did not play a major part in the campaign to legalise abortion. There were exceptions, such as Alick Bourne, whose courageous act in carrying out an abortion on a rape victim established, by his subsequent acquittal, the principle that the mental health of women could be taken into account in determining whether health grounds for abortion existed. There were a few other obstetricians who were prepared to sail close to the wind in applying a liberal interpretation of the old restrictive law, a courageous act when the penalty was imprisonment and abortion was one of the ‘As’ for which doctors would usually be struck off. Conscience was unfortunately the motivator only for some – those who could pay could usually get an abortion, if they knew where to ask.

The majority of doctors defended the old law, and gynaeocologists treated the sick, dying and maimed victims of the back street abortionist with barely a protest at the law which murdered them.

Indeed shortly after the 1967 Act had been passed the Royal College of Obstetricians and Gynaecologists protested that women were dying of womb cancer because beds were blocked by abortion patients. The claim was absurd since the resources involved in an abortion are less than those involved in the birth of a child (an argument which also gives the lie to health authorities who justify their poor performance in providing abortions by saying that they cannot afford it).

By the late 1970s, however, the climate of opinion had changed, and the profession had come to welcome the new law. The BMA and the Royal College both opposed the Corrie Bill.

In Northern Ireland, where the 1967 Act does not apply, the profession continues to hold to its old views. The 1983 ARM passed a resolution calling for the 1967 Act to be extended to Northern Ireland. The Northern Ireland Council of the BMA resisted this, claimed that it would divide the profession, and BMA Council accepted that opinion and decided to take no action on it. However the 1984 ARM reiterated the policy, despite the pleas of the Northern Ireland Council.

The MPU also participated in the defence of the 1967 Act against the attacks that were made on it, by proposing a motion at the 1978 TUG committing the TUG to participating in the defence of the Act. This was an important intervention since it led to the TUG organising a demonstration against the Corrie Bill.

Two years later, in 1980, the MPU proposed a motion on women’s health which included a call for day-care abortion facilities. This was also passed and became TUG policy.

The mainstay of the profession’s resistance to erosion of the 1967 Act has been an organisation established specially for this issue, Doctors for a Women’s Choice on Abortion, which organised the highly effective medical lobby of Parliament against the Corrie Bill.

On family planning the record of the profession has been less good. Family-planning clinics were established in the volun­tary sector by the Family Planning Association, and encountered hostility from the profession. Indeed the Medical Defence Union initiated a successful complaint of advertising to the CMC against one of the leading family-planning doctors for making public statements about the clinics.

After the NHS reorganisation of 1974, family-planning clinics were brought into the NHS by agreement with the FPA, but they have been the subject of unremitting hostility from general practitioners who want to provide family-planning services for their own patients, especially now that they are paid extra for doing so.

Although many women find it convenient to use family-planning services provided by their GPs, especially where the GP provides a good service, many dislike their own GP’s approach, many wish to discuss family planning with a different doctor from the one with whom they discuss their normal medical problems, many have conflicts with husbands or parents who share their GP, many see fertility control as part of the process of being a woman not a medical problem and want to receive advice from a doctor who appreciates that difference and many have male GPs but prefer to discuss family planning with a woman. There are also limits on the GP service (barrier methods are not widely available, despite the strong medical arguments for using them to avoid cervical cancer), some GPs refuse to provide it on religious grounds and the quality of the service provided by some GPs is very poor.

Despite this, GPs in many localities put every conceivable obstacle in the way of the family-planning clinic, and GP representatives nationally continue to campaign for the transfer of family planning entirely into general practice and to oppose the introduction of a proper career structure for doctors working in it.

Feminists, however, argue that the family planning clinics are not enough and call for the establishment of well-women clincs. The case for well-women clinics is that some women’s health issues, such as fertility control, menstrual problems, cervical screening and so on, are not illnesses but are part of normal life. They require information, sympathetic coun­selling and sharing of experiences rather than treatment as a patient. This is especially a problem when the doctor is a man – it is in a way patriarchy’s ultimate territorial demand that even the process of being a woman needs to be controlled by men.

Although some health authorities have applied the title ‘well-women clinic’ to clinics which offer cervical cytology and family planning on fairly traditional lines, only South Manchester has established a well-women clinic within the NHS on a feminist model. All the workers are women and the presence of men at the clinic premises is discouraged. Before seeing the doctor women discuss their problems with a volunteer, called a ‘generalist’, who provides sympathetic advice and describes what else the clinic offers. The women can then choose to see a nurse (who carries out various screening procedures) and then, if she wishes, the doctor. A programme of skill sharing takes place within the clinic. The clinic has open access and does not require GP referral.

The development of clinics on this model would certainly be resisted by the medical profession in most areas. GPs generally oppose open-access clinics believing that they detract from their own role. The self-help element and the role of the volunteers would be the subject of strong suspicion.

The MPU has supported well-women clinics and embodied support for the concept in its motion on women’s health at the 1980 TUG, so that support for the concept is now TUG policy. However within the medical profession the MPU’s stance on this matter is very much isolated.

What do you think?

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