Susan P. Phillips

Defining and measuring gender: a social determinant of health whose time has come.

This paper contributes to a nascent scholarly discussion of sex and gender as determinants of health. Health is a composite of biological makeup and socioeconomic circumstances. Differences in health and illness patterns of men and women are attributable both to sex, or biology, and to gender, that is, social factors such as powerlessness, access to resources, and constrained roles. Using examples such as the greater life expectancy of women in most of the world, despite their relative social disadvantage, and the disproportionate risk of myocardial infarction amongst men, but death from MI amongst women, the independent and combined associations of sex and gender on health are explored. A model for incorporating gender into epidemiologic analyses is proposed.

Determinants of a healthy lifestyle and use of preventive screening in Canada

BackgroundThis study explores the associations between individual characteristics such as income and education with health behaviours and utilization of preventive screening.MethodsData from the Canadian National Population Health Survey (NPHS) 1998–9 were used. Independent variables were income, education, age, sex, marital status, body mass index, urban/rural residence and access to a regular physician. Dependent variables included smoking, excessive alcohol use, physical activity, blood pressure checks, mammography in past year and Pap smear in past 3 years. Logistic regression models were developed for each dependent variable.Results13,756 persons 20 years of age and older completed the health portion of the NPHS. In general, higher levels of income were associated with healthier behaviours, as were higher levels of education, although there were exceptions to both. The results for age and gender also varied depending on the outcome. The presence of a regular medical doctor was associated with increased rates of all preventive screening and reduced rates of smoking.ConclusionThese results expand upon previous data suggesting that socioeconomic disparities in healthy behaviours and health promotion continue to exist despite equal access to medical screening within the Canadian healthcare context. Knowledge, resources and the presence of a regular medical doctor are important factors associated with identified differences.

Levels of dechlorane plus and polybrominated diphenylethers in human milk in two Canadian cities

Flame retardant dechlorane plus (DP) and several polybrominated diphenylether (PBDE) congeners have been measured in 87 human milk samples collected in two Canadian cities: Kingston and Sherbrooke. The levels of PBDEs in human milk (mean (median), ng g(-1) lipid weight=10 (5.9), 4.1 (2.8), 3.0 (1.6), 5.12 (1.6), and 15 (ND) for BDE-47, BDE-99, BDE-100, BDE-153, and BDE-209, respectively) were comparable to those reported in Europe, U.S.A. and China. The levels of DP, with a mean value of 0.98 ng g(-1) and a median value of 0.60 ng g(-1) (lipid weight), were two to ten times lower than those of concurrently measured major PBDEs including BDE-209. While there is little difference in the levels of measured contaminants in milk samples collected from the two cities, the contaminants levels in human milk show, indicated by Principal Components Analysis, that DP, deca-BDE, and penta-BDE come from three distinct sources. The mean and median isomer ratio values of DP in milk were 0.67 and 0.69, respectively, very similar to that of DP commercial products.

The Feminization of Medicine and Population Health

OVER THE PAST CENTURY, WOMEN HAVE MOVED from near exclusion from medical schools toward forming the majority of new graduates in medicine, a trend referred to as “the feminization of medicine.” While eliminating barriers to entry is a matter of equity and fairness, it has been argued that the real influence of this feminization will be a humanization of the profession and the care it provides. In reality, the shift toward values that are stereotypically female may be unrelated to a shifting sex makeup of the profession, but rather may have resulted from consumer demand, litigation, or evidence of best practices. On the other hand, a critical mass of female physicians may have contributed to the changes that now make medicine a more welcoming place for women and men, both as patients and practitioners. Nevertheless, working patterns of female physicians in developed countries have prompted concern that women in medicine are either the cause of, or will exacerbate, physician shortages. In this Commentary, we describe the career choices of women physicians and the contribution of medical care to decreasing mortality rates and hypothesize that the feminization of medicine is good for health outcomes. A review of specialty choices of male and female medical school graduates in Canada, the United Kingdom, and the United States shows that although the numbers of women in medical schools have increased steadily over the past 5 decades, women remain a minority in some specialties and overrepresented in others. Female medical students are more likely to become primary care clinicians such as family physicians and pediatricians rather than subspecialists or surgeons. In 2007, 33% of Canadian female medical graduates (n=393) entered family medicine training whereas only 22% of their male counterparts (n=184) chose this specialty. Women account for a minority of currently practicing Canadian physicians (37.9%) but a majority of that country’s family physicians (58.6%). In the United States, fewer than half of medical school graduates are women (43.5%), but they account for the majority of residents in primary care programs. Data from the United Kingdom show similar distributions of men and women currently in medical practice. This pattern of women being disproportionately represented among generalist physicians is similar throughout Europe and Australia. Recent reports identifying lower productivity among female physicians have debated whether more women in medicine will exacerbate a shortage of physicians by limiting patient access to care. Differences in how men and women practice medicine are well documented and relatively consistent across countries. In general, women are less likely to work excessive hours or to work past the typical age of retirement. Female physicians see fewer patients per hour, demonstrate better communication skills, and include more preventive care than their male counterparts. However, there are no published studies documenting whether increases in the female-to-male ratio, that is, the feminization of medicine, will affect health outcomes. What bearing does physician density and activity have on measurable health outcomes such as mortality rates? Do either quantity or quality of clinical care influence standard measures of population health? How will sex shifts within the physician workforce interact with these effects? In developed countries, the number of physicians per capita, alone and separated from any analysis of the nature of care provided, has no association with mortality rates. In 1978, Cochrane examined how a number of proximate factors, including gross domestic product, physician density, sugar consumption, and cigarette smoking, were associated with mortality rates in 1960 and 1970 across 18 developed countries. He found no association between physician density and any of the standard mortality rates and concluded that health service factors were relatively unimportant in explaining differences in mortality among developed countries. The disconnect between physician density and outcomes is neither a historic nor a statistical artifact. Current World Health Organization data for the same 18 countries show little change from the findings by Cochrane et al 3 decades ago. Canada has the lowest physician density (19 per 10 000) of these wealthy, developed countries but has a female life expectancy of 83 years and a male life expectancy of 78 years. In the United States, with a higher physician density (26 per 10 000), life expectancies for women

More than an education: the hidden curriculum, professional attitudes and career choice

Medical Education 2012: 46: 887–893

A qualitative study of sexual harassment of female doctors by patients

This paper reports the qualitative data from a study of sexual harassment of female family physicians by patients. In addition to the everyday harassment that any woman might encounter in a work setting, the physicians in this study also reported types of harassment which are unique to the practice of medicine. These include opportunistic harassment such as exposure of the genitals, inappropriately touching the physician when the examination requires close contact, excessive discussion of sexual matters for apparent erotic gratification, and acting out behaviours from non-competent patients. Other reported behaviours were not, strictly speaking, sexual harassment but were troublesome nonetheless, including spontaneous erections during physical examinations, physically intimidating behaviour, and ambiguous behaviours which were sexual in nature, but difficult to interpret. The findings are discussed in the context of theory pertaining to contrapower harassment. It is concluded that for some patients the gender of the physician takes precedence over her occupational status and, this combined with the unique characteristics of the doctor/patient relationship, can make the practice of family medicine more conductive to sexual harassment than other professions.

Measuring the health effects of gender

The health effects of gender are mediated via group-level constraints of sex roles and norms, discrimination and marginalisation of individuals, and internalisation of the stresses of role discordance. Although gender is frequently a lens through which data are interpreted there are few composite measures that insert gender as an independent variable into research design. Instead, sex disaggregation of data is often conflated with gender, identifying statistically significant but sometimes clinically insignificant sex differences. To directly assess the impact of gender on wellbeing requires development of group and individual-level derived variables. At the ecological level such a summative variable could be composed of a selection of group-level measures of equality between sexes. This gender index could be used in ecological and individual-level studies of health outcomes. A quantitative indicator of gender role acceptance and of the personal effects of gender inequities could insert the often hidden variable of gender into individual-level clinical research.

Lifecourse adversity and physical performance across countries among men and women aged 65-74.

Background This study examines the associations between lifecourse adversity and physical performance in old age in different societies of North and South America and Europe. Methods We used data from the baseline survey of the International Study of Mobility in Aging, conducted in: Kingston (Canada), Saint-Hyacinthe (Canada), Natal (Brazil), Manizales (Colombia) and Tirana (Albania). The study population was composed of community dwelling people between 65 and 74 years of age, recruiting 200 men and 200 women at each site. Physical Performance was assessed with the Short Physical Performance Battery (SPPB). Economic and social adversity was estimated from childhood adverse events, low education, semi-skilled occupations during adulthood and living alone and insufficient income in old age. Results A total of 1995 people were assessed. Low physical performance was associated with childhood social and economic adversity, semi-skilled occupations, living alone and insufficient income. Physical performance was lower in participants living in Colombia, Brazil and Albania than in Canada counterparts, despite adjustment for lifecourse adversity, age and sex. Conclusions We show evidence of the early origins of social and economic inequalities in physical performance during old age in distinct populations and for the independent and cumulative disadvantage of low socioeconomic status during adulthood and poverty and living alone in later life.

Gender Differences: Examination of the 12-Item Bem Sex Role Inventory (BSRI-12) in an Older Brazilian Population

Objectives Although gender is often acknowledged as a determinant of health, measuring its components, other than biological sex, is uncommon. The Bem Sex Role Inventory (BSRI) quantifies self-attribution of traits, indicative of gender roles. The BSRI has been used with participants across cultures and countries, but rarely in an older population in Brazil, as we have done in this study. Our primary objective was to determine whether the BSRI-12 can be used to explore gender in an older Brazilian population. Methods The BSRI was completed by volunteer participants, all community dwelling adults aged 65+ living in Natal, Brazil. Exploratory factor analysis was performed, followed by a varimax rotation (orthogonal solution) for iteration to examine the underlying gender roles of feminine, masculine, androgynous and undifferentiated, and to validate the BSRI in older adults in Brazil. Results The 278 participants, (80 men, 198 women) were 65–99 years old (average 73.6 for men, 74.7 for women). Age difference between sexes was not significant (p = 0.22). A 12 item version of the BSRI (BSRI-12) previously validated among Spanish seniors was used and showed validity with 5 BSRI-12 items (Cronbach=0.66) loading as feminine, 6 items (Cronbach=0.51) loading onto masculine roles and neither overlapping with the category of biological sex of respondent. Conclusions Although the BSRI-12 appears to be a valid indicator of gender among elderly Brazilians, the gender role status identified with the BSRI-12 was not correlated with being male or female.

Including Gender in Public Health Research

Diversity in both biological attributes and the external, lived environment gives rise to different susceptibilities, exposures, health outcomes, and longevity. Public policy can modify the effects of external differences, if groups at greatest risk are identified and pathways to excess vulnerability are understood, by rebalancing and redistributing the inputs or social determinants that work their way under the skin to ultimately cause biological disadvantage. In the past three decades, a large volume of research has identified the nature of these social determinants of health—including income, socioeconomic status (SES), income inequality, social connectedness, and social capital—and the pathways by which they undermine or reinforce innate health. Often listed among these, but rarely studied, is gender. Medical research may identify sex differences when they exist; however, the varied social roles, expectations, and constraints experienced by men and women in a given society go well beyond the individual and sex differences and are rarely examined as inputs responsible for variation in health outcomes. As a result, health-affirming policies tend to homogenize groups (e.g., assuming that all women are the same) or target individual behaviors, and do so in a gender-blind fashion rather than addressing structural biases and inequities that undermine those behaviors. This article explores the nature of gender as a determinant of health and describes how the effects of gender inequities can be included in health outcomes research that can then shape health planning and policy.