"Trailed only by Spain and Madagascar, the United States ranks near the bottom in statistics on women doctors, it was revealed last month at the International Conference on Women in Health here." So read the opening statement of a news item in a paper published in the nation's capital. Of significance, especially as related to the subject of the article, is the fact that the news story appeared six weeks after the event. One is prompted to assume that the editors saw the conference, which was well attended by women health givers and consumers from a number of foreign countries as well as our own, as of limited significance and interest to the public.
Obviously, discrimination against women is not limited to the press. The overlooking and disparaging of issues related to women as consumers and deliverers of health care services are equally apparent in some circles of medicine, including psychiatry. Campbell (1973) writes: "It is clear that there is a direct relationship between discrimination against women as medical students and as patients: the one supports the other. We have seen that the medical school environment permits or encourages some kinds of blatantly discriminatory attitudes. . . ." Medical school deans and members of admission committees, most of them men, insist that there is no sex discrimination in their admission policies. Yet in far too many instances, women applicants continue to be asked questions related to marriage and pregnancy. A woman colleague, while a member of the faculty of a well-known East Coast medical school, made a number of observations that depict institutionalized sexism. A major administrative change consisted of the development of a system of deans. The positions of three deans and several associate deans were filled by white men. The school was said to be implementing an affirmative action program, but no positions higher than the rank of assistant professor were filled by women (or by minorities). An additional slight: there were no women members of the "powerful" committees, such as curriculum and faculty promotions. The colleague observed academia to be divided into two parts, the served and those serving; the latter, composed mostly of women, were the auxiliary personnel and often included the women faculty. It was her impression that women are diagnosed rather than dealt with by male psychiatrists. In other situations, women professionals are ignored by male colleagues. A frequent observation: a male colleague addresses a professional group (of men and women) as "gentlemen" - perhaps adding "ladies" as an afterthought, perhaps not.
Lopate (1968) cites facts and figures that confirm her statements: "Professional advancement in the medical world is one area where those women who claim prejudice have the facts on their side. Women do not advance in staff position in the medical schools, hospitals, or other institutions at the same rate as men." In numerous instances, women appointed to top administrative posts find they have considerable responsibility, but the limited authority impedes the fulfillment of the identified responsibilities. A departmental chairperson found this to be so when top medical administrators made decisions about the operation of a service that was a unit of the department. A woman physician appointed to an important administrative post reported that she had been excluded from participation in meetings during which major administrative decisions were made.
Campbell (1973) writes of stereotyping as another form of discrimination. We frequently hear that a woman not only takes a man's place in medical school but is more likely to drop out or not practice. However, we seldom hear this generalization attributed to men, even though we may hear that Armand Hammer, John Locke, W. Somerset Maugham, and A. J. Cronin, among other men, completed medical school. This is not to deny the attrition rate of women medical students. However, it is lower, as determined by Ris (1974), than commonly assumed - 9 per cent for men, 15 per cent for women. Ris writes, "The attrition for academic reasons has no relation to sex. Marriage per se doesn't cause attrition, but children do; this, because of lack of domestic help or day care facilities."
Sullivan (1974) reports the results of two surveys: 83.5 per cent and 91 per cent of women physicians were professionally active. Lopate (1968) refers to a preliminary report (by Powers, Wiesenfelder, and Parmelee) of patterns of men and women practicing physicians who graduated between 1931 and 1956; nearly 9 per cent of the women were inactive, and only 54.5 per cent practiced full time (compared with figures for men physicians of 1 per cent and 88.8 per cent). However, as is also pointed out, "since women doctors have consistently accepted salaried positions more willingly than men, the increasing demand for physicians in hospitals, clinics, and health centers should work in favor of admitting more women into medicine, as should the fact that they enter specialties of increasingly acute need, such as pediatrics, psychiatry, and public health."
A male professor "complimented" a woman medical student on her dress. He remarked that the dress was pretty and added that she looked great but did not look like a woman doctor. A woman colleague recalls being told, as a medical student, that she was not aggressive or decisive enough, but when she did become more so she was criticized for not being feminine. Notman and Nadelson (1973) discuss this dilemma as being rooted in early patterns of child rearing. "Girls in our culture are usually encouraged to choose more passive types of activities because these are considered to be more feminine and more consistent with their later roles. Scientific pursuits in particular are frowned upon and considered to be masculine because of their association with asserti veness, precision and responsibility." In an earlier publication, Cohen (1966) noted similar observations, as did Homey (1926) and Thompson (1942). Cohen (1966) also called attention to "the startling belief among many of us that most of the neurotic illness in our population is mother-generated. . . . The psychoanalytic theories of infant and early childhood development have certainly played an influential part in introducing a sense of guilty responsibility into the transactions between mother and child, which goes far toward undermining the spontaneity of their relationship."
Cohen speculated that efforts to look at the family as a unit might well redirect our approach. In spite of the growing emphasis on including the entire family in psychiatric evaluations of a disturbed or disturbing child, the mother-generated theory appears firmly rooted in the formulations proposed by many of our psychiatric colleagues. Recently, during a consultation session at a community mental health center, the writer was provided with a report of a diagnostic evaluation of a latency-aged girl. The social worker and the examining psychiatrist, known to be a skillful and competent clinician, had interviewed both parents. However, the formulation of the case included no reference to the father or to the fatherchild or father-mother interaction. Here, again, the child's disorder was seen as stemming only from the mother-child interaction.
The results of a study of sexrole stereotypes and clinical judgments of mental health professionals, conducted by Broverman et al., supported the hypothesis that "(a) clinicians have different concepts of health for men and women and (b) these differences parallel sex-role stereotypes prevalent in our society." In other words, it was determined that clinicians hold to a double standard of health. The investigators ruled out biologic differences (between men and women) as a sound reason for the conclusion. They pointed to the overlap between the sexes with regard to a number of characteristics (such as objectivity, independence, logical ability), and the variations in each sex suggest:
. . . the double standard of health for men and women stems from the clinicians' acceptance of an "adjustment" notion of health; for example, health consists of a good adjustment to one's environment. In our society, men and women are systematically trained, practically from birth, to fulfill different roles. An adjustment notion of health, plus the existence of differential norms of male and female behavior in our society, automatically leads to a double standard of health. Thus, for a woman to be healthy, from an adjustment viewpoint, she must adjust to and accept the behavioral norms for her sex, even though these behaviors are generally less socially desirable and considered less healthy for the generalized competent mature adult.
Prather and Fidell (1972) reported an in-depth analysis of medical advertisements placed in several medical journals. A number of observations pointed to sexist attitudes. Not one advertisement portrayed a woman as a physician; the use of sex stereotypes was prominent. Women were portrayed as emotional, irrational, and complaining; men were illustrated primarily as independent and stoic. A recent cursory survey shows that many of the medical advertisements continue to reflect these biases. A thorough search of six monthly issues of a well-circulated psychiatric journal pointed up some significant facts. Of the 119 advertisements that related to the use of drugs for psychiatric disorders, 57 were unrelated to gender identity. However, only one advertisement depicted a male adult as the identified patient; 31 illustrated the patient to be a woman, and 13 patients were illustrated as male children. Similar observations were made in a perusal of two other psychiatric journals. Also significant was the observation that only one company illustrated a woman as an apparent therapist. One must conclude that sexism is alive and continues to be displayed in medical advertising.
The foregoing addresses only a few of the numerous sources of sexism in medicine. Efforts directed toward changes in these practices also spring from many sources. Progress is being made, but we have a long way to go. I hope that all medical men and women will join in the struggle to free medicine from gender discrimination.