Mainstreaming a Gender Perspective into the Medical Curriculum: Why Bother?

1. Mainstreaminga 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, 17th June 2003

2. Ann-Maree Nobelius • Monash graduate, Physiology and Pharmacology & Masters in Reproductive Sciences • medical research background • further studies in sociological research methodology particularly gender studies • 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 • Project Officer for Gender Working Party with goal of mainstreaming a gender perspective into entire curriculum

3. Outline of Presentation • Whatis gender mainstreaming? • Why bother? • Who is doing it/what has worked what hasn’t? • Whatdo we want to achieve& Howdo we do it? • Costs & Benefits

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

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

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

7. 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’

8. Misunderstandings… • ‘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’ • 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) • MEN HAVE GENDER TOO

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

10. 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) • Following emergency room treatment for unstable angina men have a greater rate of procedures than women and suffer worse outcomes (Rogers,2000 JAMA)

11. 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

12. 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) • Normal GFR [Female GFR] (RACGP)

13. Outline of Presentation • What • Why bother • Who • What & How • Costs & Benefits

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

15. Gender-blindness inmedical research • 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 • women have only made up 7% of all cardiac research subjects • 1 in 3 women die of heart disease in Australia

16. Why is it ‘gender blind’? • 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 • 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

17. Gender differences in health (slide c/o Rob McLachlan, Andrology Australia) • 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 A variety of risk behaviours contribute to poorer health status

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

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

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

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

22. Take home messages… • the process must be evidence based and balanced • men have gender issues too • 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

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

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

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

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

27. Columbia* Partnership for Gender-specific Medicine • Research • Publications • Free Web-based journal http://www.mmhc.com/jgsm/

28. 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. • To be done well this process should follow a development process similar to that successfully conducted within UN agencies since 1998

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

30. What are we trying to achieve with gender mainstreaming in the curriculum at Monash? • 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 • That is what we have commenced through the activities of the gender working party

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

32. Outline of Presentation • What • Why • Who • What & How • Costs & Benefits

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

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