Women in medicine

The presence of women in medicine, particularly in the practicing fields of surgery and as physicians, has been traced to earliest human history. Women have historically had lower participation levels in medical fields compared to men with occupancy rates varying by race, socioeconomic status, and geography.

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Women's informal practice of medicine in roles such as caregivers, or as allied health professionals, has been widespread. Since the start of the 20th century, most countries of the world provide women with equal access to medical education. Not all countries ensure equal employment opportunities,[1] and gender equality has yet to be achieved within medical specialties and around the world,[2] studies suggesting that female doctors may be providing higher-quality care than male doctors.[3][4][5]

History

Ancient medicine

The involvement of women in the field of medicine has been recorded in several early civilizations. An Egyptian of the Early Dynastic Period or Old Kingdom of Egypt, Merit-Ptah, described in an inscription as "chief physician", is the earliest woman named in the history of science.[6][7] Agamede was cited by Homer as a healer in ancient Greece before the Trojan War. Agnodice was the first female physician to practice legally in 4th century BC Athens. Metrodora was a physician and generally regarded as the first medical writer.[8] Her book, On the Diseases and Cures of Women, was the oldest medical book written by a female and was often referenced by many other female physicians.[8] She credited much of her writings to the ideologies of Hippocrates.[8]

Medieval Europe
Hildegard of Bingen, a Medieval German abbess who wrote Causae et Curae, 1175.

During the Middle Ages, convents were a centralized place of education for women, and some of these communities provided opportunities for women to contribute to scholarly research. An example is the German abbess Hildegard of Bingen, whose prolific writings include treatments of various scientific subjects, including medicine, botany and natural history (c. 1151–58).[9] She is considered Germany's first female physician.[10]

Women in the Middle Ages participated in healing techniques and capacities. Women occupied select ranks of medical personnel during the period.[11] They worked as herbalists, midwives, surgeons, barber-surgeons, nurses, and traditional empirics.[12] Women healers treated most patients, not limiting themselves to treating solely women. The names of 24 women described as surgeons in Naples, Italy between 1273 and 1410 have been recorded, and references have been found to 15 women practitioners, most of them Jewish and none described as midwives, in Frankfurt, Germany between 1387 and 1497.[13]

Women also engaged in midwifery and healing arts without having their activities recorded in written records, and practiced in rural areas or where there was little access to medical care. Society in the Middle Ages limited women's role as physician. Once universities established faculties of medicine during the thirteenth century, women were excluded from advanced medical education.[11] Licensure began to require clerical vows for which women were ineligible, and healing as a profession became male-dominated.[12]

In many occasions, women had to fight against accusation of illegal practice done by males, putting into question their motives. If they were not accused of malpractice, then women were considered "witches" by both clerical and civil authorities.[14] Surgeons and barber-surgeons were often organized into guilds, they could hold out longer against the pressures of licensure. Like other guilds, a number of the barber-surgeon guilds allowed the daughters and wives of their members to take up membership in the guild, generally after the man's death. Katherine la surgiene of London, daughter of Thomas the surgeon and sister of William the Surgeon belonged to a guild in 1286.[15] Documentation of female members in the guilds of Lincoln, Norwich, Dublin and York continue until late in the period.

Midwives, those who assisted pregnant women through childbirth and some aftercare, included only women. Midwives constituted roughly one third of female medical practitioners.[12] Men did not involve themselves in women's medical care; women did not involve themselves in men's health care.[16] The southern Italian coastal town of Salerno was a center of medical education and practice in the 12th century. In Salerno the physician Trota of Salerno compiled a number of her medical practices in several written collections. One work on women's medicine that was associated with her, the De curis mulierum ("On Treatments for Women") formed the core of what came to be known as the Trotula ensemble, a compendium of three texts that circulated throughout medieval Europe. Trota herself gained a reputation that spread as far as France and England. There are also references in the writings of other Salernitan physicians to the mulieres Salernitane ("Salernitan women"), which give some idea of local empirical practices.[17]

Dorotea Bucca, an Italian physician, was chair of philosophy and medicine at the University of Bologna for over forty years from 1390.[18][19] Other Italian women whose contributions in medicine have been recorded include Abella, Jacqueline Felice de Almania, Alessandra Giliani, Rebecca de Guarna, Margarita, Mercuriade (14th century), Constance Calenda, Clarice di Durisio (15th century), Constanza, Maria Incarnata and Thomasia de Mattio.[20][21]

Medieval Islamic world

For the medieval Islamic world, little information is known about female medical practitioners although it is likely that women were regularly involved in medical practice in some capacity.[22] Male medical writers refer to the presence of female practitioners (a ṭabība) in describing certain procedures or situations.[22] The late-10th to early-11th century Andalusi physician and surgeon al-Zahrawi wrote that certain medical procedures were difficult for male doctors practicing on female patients because of the need to touch the genitalia.[22] The male practitioner was required to either find a female doctor who could perform the procedure, or a eunuch physician, or a midwife who took instruction from the male surgeon.[22] The existence of female practitioners can be inferred, albeit not explicitly, through direct evidence.[22] Midwives played a prominent role in the delivery of women's healthcare. For these practitioners, there is more detailed information, both in terms of the prestige of their craft (ibn Khaldun calls it a noble craft, "something necessary in civilization") and in terms of biographical information on historic women.[23][24] To date, no known medical treatise written by a woman in the medieval Islamic world has been identified.

Western medicine in China

Traditional Chinese medicine based on the use of herbal medicine, acupuncture, massage and other forms of therapy has been practiced in China for thousands of years. Western medicine was introduced to China in the 19th Century, mainly by medical missionaries sent from various Christian mission organizations, such as the London Missionary Society (Britain), the Methodist Church (Britain) and the Presbyterian Church (US). Benjamin Hobson (1816–1873), a medical missionary sent by the London Missionary Society in 1839, set up the Wai Ai Clinic (惠愛醫館)[25][26] in Guangzhou, China. The Hong Kong College of Medicine for Chinese (香港華人西醫書院) was founded in 1887 by the London Missionary Society, with its first graduate (in 1892) being Sun Yat-sen (孫中山).

Due to the social custom that men and women should not be near to one another, Chinese women were reluctant to be treated by Western male doctors. This resulted in a need for female doctors. One of these was Sigourney Trask of the Methodist Episcopal Church, who set-up a hospital in Fuzhou during the mid-19th century. Trask also arranged for a local girl, Hü King Eng, to study medicine at Ohio Wesleyan Female College, with the intention that Hü would return to practise western medicine in Fuzhou. After graduation, Hü became the resident physician at Fuzhou's Woolston Memorial Hospital in 1899 and trained several female physicians.[27] Another female medical missionary Mary H. Fulton (1854–1927)[28] was sent by the Foreign Missions Board of the Presbyterian Church (US) to found the first medical college for women in China. Known as the Hackett Medical College for Women (夏葛女子醫學院),[29][30][31][32] this college was located in Guangzhou, China, and was enabled by a large donation from Edward A. K. Hackett (1851–1916) of Indiana. The college was dedicated in 1902 and offered a four-year curriculum. By 1915, there were more than 60 students, mostly in residence. Most students became Christians, due to the influence of Fulton. The college was aimed at the spreading of Christianity and modern medicine and the elevation of Chinese women's social status. The graduates of this College included Chau Lee-sun (周理信, 1890–1979) and Wong Yuen-hing (黃婉卿), both of whom graduated in the late 1910s and then practiced medicine in the hospitals in Guangdong province.

Midwifery in 18th century America

Out of the different occupations women took on around this time, midwifery was one of the highest-paying industries.[33] In the 18th century, households tended to have an abundance of children largely in part to having hired help and diminished mortality rates.[34] Despite the high chance of complications in labor, American midwife Martha Ballard, specifically, had high success rates in delivering healthy babies to healthy mothers.[33]

Women's health movement, 1970s

The 1970s marked an increase of women entering and graduating from medical school in the United States.[35] From 1930 to 1970, a period of 40 years, around 14,000 women graduated from medical school.[35] From 1970 to 1980, a period of 10 years, over 20,000 women graduated from medical school.[35] This increase of women in the medical field was due to both political and cultural changes. Two laws in the U.S. lifted restrictions for women in the medical field – Title IX of the Higher Education Act Amendments of 1972 and the Public Health Service Act of 1975, banning discrimination on grounds of gender.[36] In November 1970, the Assembly of the Association of American Medical Colleges rallied for equal rights in the medical field.[36]

Throughout the decade women's ideas about themselves and their relation to the medical field were shifting due to the women's feminist movement.[37] A sharp increase of women in the medical field led to developments in doctor-patient relationships, changes in terminology and theory.[37] One area of medical practice that was challenged and changed was gynecology.[37] Author Wendy Kline noted that "to ensure that young brides were ready for the wedding night, [doctors] used the pelvic exam as a form of sex instruction."[38]

With higher numbers of women enrolled in medical school, medical practices like gynecology were challenged and subsequently altered.[39] In 1972, the University of Iowa Medical School instituted a new training program for pelvic and breast examinations.[39] Students would act both as the doctor and the patient, allowing each student to understand the procedure and create a more gentle, respectful examination.[39] With changes in ideologies and practices throughout the 70s, by 1980 over 75 schools had adopted this new method.[39]

Along with women entering the medical field and feminist rights movement, came along the women's health movement which sought alternative methods of health care for women. This came through the creation of self-help books, most notably Our Bodies, Ourselves: A Book by and for Women.[40] This book gave women a "manual" to help understand their body. It challenged hospital treatment, and doctors' practices.[40] Aside from self-help books, many help centres were opened: birth centres run by midwives, safe abortion centres, and classes for educating women on their bodies, all with the aim of providing non-judgmental care for women.[41] The women's health movement, along with women involved in the medical field, opened the doors for research and awareness for female illness like breast cancer and cervical cancer.[41]

Scholars in the history of medicine had developed some study of women in the field—biographies of pioneering women physicians were common prior to the 1960s—and study of women in medicine took particular root with the advent of the women's movement in the 1960s, and in conjunction with the women's health movement.

Modern medicine
Wafaa El-Sadr, Egyptian epidemiologist and MacArthur Fellow, 2010.
Monique Frize (centre), Canadian academic and biomedical engineer, 2008.
Awa Marie Coll-Seck, Senegal's former Minister of Health, in 2009.

In 1540, Henry VIII of England granted the charter for the Company of Barber-Surgeons;[42] while this led to the specialization of healthcare professions (i.e. surgeons and barbers), women were barred from professional practice.[43] Women did continue to practice during this time without formal training or recognition in England and eventually North America for the next several centuries.[43]

Women's participation in the medical professions was generally limited by legal and social practices during the decades while medicine was professionalizing.[44] Women openly practiced medicine in the allied health professions (nursing, midwifery, etc.), and throughout the nineteenth and twentieth centuries, women made significant gains in access to medical education and medical work through much of the world. These gains were sometimes tempered by setbacks; for instance, Mary Roth Walsh documented a decline in women physicians in the US in the first half of the twentieth century, such that there were fewer women physicians in 1950 than there were in 1900.[45] Through the latter half of the twentieth century, women made gains generally across the board. In the United States, for instance, women were 9% of total US medical school enrollment in 1969; this had increased to 20% in 1976.[45] By 1985, women constituted 16% of practicing American physicians.[46]

At the beginning of the 21st-century in industrialized nations, women have made significant gains, but have yet to achieve parity throughout the medical profession. Women have achieved parity in medical school in some industrialized countries, since 2003 forming the majority of the United States medical school applicants.[47] In 2007–2008, women accounted for 49% of medical school applicants and 48.3% of those accepted.[48] According to the Association of American Medical Colleges (AAMC) 48.4% (8,396) of medical degrees awarded in the US in 2010–2011 were earned by women, an increase from 26.8% in 1982–1983.[49] While more women are taking part in the medical field, a 2013–2014 study reported that there are significantly fewer women in leadership positions within the academic realm of medicine. This study found that women accounted for 16% of deans, 21% of the professors, and 38% of faculty, as compared to their male counterparts.[50]

The practice of medicine remains disproportionately male overall. In industrialized nations, the recent parity in gender of medical students has not yet trickled into parity in practice. In many developing nations, neither medical school nor practice approach gender parity. Moreover, there are skews within the medical profession: some medical specialties, such as surgery, are significantly male-dominated,[51] while other specialties are significantly female-dominated, or are becoming so. In the United States, female physicians outnumber male physicians in pediatrics and female residents outnumber male residents in family medicine, obstetrics and gynecology, pathology, and psychiatry.[52][53]

Women continue to dominate in nursing. In 2000, 94.6% of registered nurses in the United States were women.[54] In health care professions as a whole in the US, women numbered approximately 14.8 million, as of 2011.[55]

Biomedical research and academic medical professions—i.e., faculty at medical schools—are also disproportionately male. Research on this issue, called the "leaky pipeline" by the National Institutes of Health and other researchers, shows that while women have achieved parity with men in entering graduate school, a variety of discrimination causes them to drop out at each stage in the academic pipeline: graduate school, postdoc, faculty positions, achieving tenure; and, ultimately, in receiving recognition for groundbreaking work.[56][57][58][59]

Glass ceiling

The "glass ceiling" is a metaphor to convey the undefined obstacles that women and minorities face in the workplace. Female physicians of the late 19th-century faced discrimination in many forms due to the prevailing Victorian Era attitude that the ideal woman be demure, display a gentle demeanor, act submissively, and enjoy a perceived form of power that should be exercised over and from within the home. Medical degrees were difficult for women to earn, and once practicing, discrimination from landlords for medical offices, left female physicians to set up their practices on "Scab Row" or "bachelor's apartments."[60]

The Journal of Women's Health surveyed physician mothers and their physician daughters in order to analyze the effect that discrimination and harassment have on the individual and their career.[61] This study included 84% of physician mothers that graduated medical school prior to 1970, with the majority of these physicians graduating in the 1950s and 1960s.[61] The authors of this study stated that discrimination in the medical field persisted after the title VII discrimination legislation was passed in 1965.[61] This was the case until 1970, when the National Organization for Women (NOW) filed a class action lawsuit against all medical schools in the United States. By 1975, the number of women in medicine had nearly tripled, and has continued to grow. By 2005, more than 25% of physicians and around 50% of medical school students were women. The increase of women in medicine also came with an increase of women identifying as a racial/ethnic minority, yet this population is still largely underrepresented in comparison to the general population of the medical field.[61]

Within this specific study, 22% of physician mothers and 24% of physician daughters identified themselves as being an ethnic minority. These women reported experiencing instances of exclusion from career opportunities as a result of their race and gender. According to this article, females tend to have lessened confidence in their abilities as a doctor, yet their performance is equivalent to that of their male counterparts. This study also commented on the impact of power dynamics within medical school, which is established as a hierarchy that ultimately shapes the educational experience.[62] Instances of sexual harassment attribute to the high attrition rates of females in the STEM fields.[63]

Competition between midwifery and obstetrics

A shift from women midwifery to male obstetrics occurs in the growth of medical practices such as the founding of the American Medical Association.[64] Instead of assisting labor in the basis of an emergency, doctors took over the delivery of babies completely; putting midwifery second.[33] This is an example of the growing sense of competition between male physicians and female midwives as a rise in obstetrics took hold. The education of women on the basis of midwifery was stunted by both physicians and public-health reformers, driving midwifery to be seen as out of practice.[65] Societal roles also played a fact in the downfall of the practice in midwifery because women were unable to obtain the education needed for licensing and once married, women were to embrace a domestic lifestyle.[64]

In 2018 there were 11,826 certified nurse midwives (CNMs).[66] In 2019 there were 42,720 active physicians in Obstetrics and Gynecology. [67]

Women's contributions to medicine in the United States

Historical women's medical schools
Woman's Medical College of Pennsylvania in 1886: Anandibai Joshi, a Marathi Hindu from India (left) with Kei Okami, a Christian from Japan (center) and Sabat Islambooly, a Kurdish-Jewish woman from Syria (right). All three completed their medical studies and each of them was the first woman from their respective countries to obtain a degree in Western medicine.

When women were routinely forbidden from medical school, they sought to form their own medical schools.

Historical hospitals with significant female involvement

18th century
  • Dorothea Erxleben (1715–1762), the first female doctor granted a M.D. in Germany, and the first woman worldwide to be granted an MD by a university.

19th century
Maria Cuțarida-Crătunescu, the first female doctor in Romania, 1857–1919. Stamp of Romania, 2007.
Elizabeth Blackwell, MD, the first woman to graduate from medical school in the United States (1849).
Russian Empress Alexandra Feodorovna with Vera Gedroitz, 1915

20th century
The small island nation of Tuvalu welcomed its first Tuvaluan female doctors in 2008 as a result of Australian aid.[107]

See also

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