Book Review

Gender, Work and Medicine

N Engl J Med 1994; 331:60July 7, 1994

Article

Gender, Work and Medicine
(Sage Studies in International Sociology [44].) Edited by Elianne Riska and Katarina Wegar. 196 pp. Newbury Park, Calif., Sage, 1993. $19.95. ISBN: 0-8039-8903-2

The audience for this book is medical sociologists, policy makers and planners concerned with health work-force issues, and those who would encourage the professional development of women. The studies in this book not only contribute to empirical knowledge of sex as a factor in the division of labor in medicine, but also challenge existing sociological approaches to the study of professionals.

The first four chapters focus on women physicians in the United States, India, Britain, and Finland. Although there is a fairly well marked segregation of the sexes according to specialty and prestige in each country, variations are quite evident. For instance, in India, because of the purdah system that radically separates the spheres of men and women, the sex typing of tasks remains common and reflects the belief of both men and women that women are best suited to caring for women and children. In Britain, however, women continue to be underrepresented in the major fields of acute care medicine, including obstetrics and gynecology. Women in Britain tend to enter the “service” fields of anesthesia, radiology, and general practice. Another feature of interest here is that increasing numbers of men are also opting for general practice, citing a wish for more regular hours and time for their families, greater security earlier in their careers (rather than competing for a post as a consultant), and a dislike of the competitiveness of hospital medicine.

The next three chapters focus on other health professionals: nurses in Britain, midwives in a number of countries, and a variety of therapists in British Columbia. An observation from the first of these chapters is that the social processes regulating the subordination of nurses reflect sexual inequalities in the wider society. Both groups of studies show that women remain concentrated in areas related to the “caring” aspects of health care, in contrast to the more prestigious “curing” aspects. However, these caring aspects tend not to be acknowledged as skills but considered qualities inherent in or natural to women. Moreover, many societies, including ours, offer scant reward to those in caretaking roles.

The only chapter to focus on women physicians in the United States is Judith Lorber's. She argues that women physicians' upward mobility has been stymied by a subtle kind of “colleague boycott” that does not keep them out entirely but prevents them from replacing men in power. She calls this process “the Salieri phenomenon” -- a combination of faint praise and subtle denigration that delegitimizes women physicians' bid to compete for positions of authority. Lorber's trenchant examination of how sexism continues to slow women's progress is marred, however, by her insistence that the men are motivated by the fear that if too many women become leaders, the profession will “tip” and become women's work, with men losing prestige, income, and authority. I believe it is really far likelier that health care reform, rather than the proportion of women, will be the main shaper of the medical profession's future prestige and access to resources.

Lorber also mentions women's success as competitors as an explanation for men's lack of support. Indeed, in some primary care specialties, women physicians' ability to recruit patients is exceeding men's, and this discrepancy may be engendering backlash. She notes that established and secure men are likely to treat women colleagues as equals, whereas insecure men keep women down with social weapons such as condescending chivalry, supportive discouragement, friendly harassment, liberated sexism, benevolent exploitation, collegial exclusion, and considerate domination. I would argue that even some secure men benevolently exploit and collegially exclude women, not as a weapon but, rather, because they are more comfortable with their traditional stereotypes of women as caretakers and mothers than with women as equals and leaders.

The concluding chapter by Wegar is a masterly analysis both of the preceding chapters' findings and of the misuse of sex as a universalizing explanatory concept. The findings lend more support to pessimistic than to optimistic interpretations of women's professional position in health care. However, an important variable in the whole scheme is how much government or corporate intrusion will diminish physicians' autonomy. That avenues for professional freedom of action remain open to physicians in Britain, Canada, and Finland despite a high degree of state involvement is a positive sign, as is the increasing number of women physicians prepared to exercise this freedom.

Janet Bickel
Association of American Medical Colleges, Washington, DC 20037