Lama Younes
White coat, smart glasses, a trimmed beard, and good old sexism: such has been the typical physician for far too long. Although modern-day medicine is attempting to push past the gendered barriers in order to advocate for equal access to care, this effort remains lacking: More than half of the global population are women and girls, yet, according to the World Health Organization (WHO), they have reduced access to quality healthcare. This reflects one of the many inequalities faced by women, girls, and non-cismen. In addition to that, Middle Eastern society has a particular form of patriarchy tied to its heightened focus on family and community values, and the medical field is not immune to such dynamics. It also displays racism among other prejudices. This affects physician-patient relationships as well as women’s access to ethical healthcare. This basic human right is particularly at risk when women belong to other oppressed groups such as racial minorities, are migrant domestic workers, or have other intersectional identities. These factors contribute to larger disparities in access to quality care among autonomous individuals, capable of identifying and communicating their needs and making their own healthcare decisions.
It has been long demonstrated that implicit bias influences healthcare decisions, which raises many questions regarding the kind and prevalence of biases medical providers might have, and their influence on the quality of care. This literature review will explore healthcare providers’ preconceived notions of women, their biased evaluations of symptoms and healthcare needs, and the poor treatment outcomes linked to these views.
Cisgender Women: The Fight for Consideration
Gender is an important factor in shaping day-to-day interactions, in manners often unnoticed and taken for granted, leading to the perpetuation of gender stereotypes. Sex characteristics and gender affect many aspects of care and treatment, and prevention guidelines that cater to gender and sex differences are important tools for equal access to care, with individual needs and specific histories in mind. However, physician-patient relationships are influenced by gendered dynamics, unrelated to sex-specific treatment, which influences physician communication styles and therefore treatment outcomes. I will begin by reviewing an interesting, new approach to the investigation of the construction of gender in cis-women’s healthcare.
When Gender Becomes Relevant in the Medical Setting
In a study exploring the approach of gynecologists and midwives in providing care to pregnant migrant women in North Italy, Elisa Rosi (2020) provides valuable insight into the contexts and ways in which gender becomes relevant to consultations. This study shows that patient-centered communication (PCC) is the most common approach taken by providers during the visits. This dialogic, two-way interaction tends to produce better results in terms of patient adherence to healthcare directives, patient satisfaction, and overall health outcomes. In the cases where PCC was employed, the consultation tended to be more personal, catered to the patient’s needs, and had a lower chance of reproducing gendered expectations while still using medical jargon. On the other hand, when husbands were present and participated in the interaction along with translators as mediators, the situation was different: doctor-centered communication (DCC) was the dominant approach. In DCC, the interaction is more like a monologue in which information and directives are given by the clinician. In these contexts, unique patient needs and interests were less prominent, and traditional gender norms made their way more easily into the conversation. In most cases and both communication styles, gender became relevant and produced gendered expectations in phases such as history taking, when the clinicians would ask about relationship status and assumed long-term heterosexual commitment, marriage, and cohabitation. In some cases, household management was assumed to be exclusively performed by women and instead of suggesting that care work is divided equally between family or partners and the tired mothers, the doctor prescribed vitamins. In the concluding remarks of consultations, sexual activity is often discussed and is one-way gender norms surface in the consultation: the patients’ male partners are depicted as more likely to want and pursue sex than their wives. Interestingly, when the husbands were present and often answered for the patient herself, the construction of gender in discussions of patients’ occupation leaned more towards one that normalizes and presupposes traditional gender roles in a rigid, depersonalized conversation that reproduces the typical male breadwinner, female housewife model.
The previous study might be a small scaled, specific setting, however, there are two facets of the article worth noting. First, given that many of the immigrants originate from Arab countries and have interactions with clinicians facilitated by moderators of the same background, it is likely that the construction of gender in these consultations was similar to the way it might be in the Arab world. Indeed, the same societal expectations of long-term, committed heterosexual relationships, traditional occupational gender roles, and preconceptions of sexual relationships that surfaced in the study are reflected in Arab women’s magazines. Further research in breaking down the construction of gender in medical consultations in the Arab context might provide more insight into the situation. Second, these findings show the importance of recognizing patterns of communication that contribute to different paths for medical consultations. The findings also shed light on the factors that may influence the heightened importance given to gender in the consultation and therefore contribute to more stereotyping. This particular link is critical for further research in order to guide efforts toward mitigating the effects of gender bias on standards of care. With that said, I will now go over some of the studies which demonstrate the influence of gender stereotypes on the notion of pain and then their influence on healthcare outcomes.
Gender Stereotypes and the Perception of Women’s Pain
One of the most common and harmful gender stereotypes dictates that women are overly emotional rather than rational (Fischer, 1993), and it is applied to women in the Arab context. They are expected to be more expressive than men and seen as more likely to report their experiences of pain. As a result, women’s pain is underestimated and men’s pain is overestimated: when controlling for both self-reported chronic shoulder pain of real videotaped patients and the subsequent expression of it, participants judged men to be in greater pain than women. In addition, the participants in the second study presented in Zhang et al. (2021)’s article were more likely to recommend painkillers for men, and psychotherapy for women. This differing perception and treatment of pain was linked to participants’ higher stereotypical beliefs about women’s and men’s pain, which was assessed using the Gender Role Expectation of Pain Questionnaire (GREP). The experiments conducted by Zhang et al. (2021) displayed reproducible findings since the first’s results were in agreement with those of the second experiment which had a large number of participants. Unsurprisingly, the same stereotypes and assumptions about the experience of pain are applied to children as well. Earp et al. (2019) found that when given the same video of a pediatric patient undergoing a medical procedure, participants judged that the child was feeling more pain if they were described as a boy, and lesser pain if described as a girl. One important limitation in these two examples is that the participants assessing patients’ pain are not healthcare professionals. Although people tend to recommend treatments for each other on a daily basis, this limitation means these studies do not necessarily demonstrate that the same sequence of mental processes and resulting actions take place in healthcare institutions. They are nevertheless highly important in demonstrating a causal relationship between gender stereotypes and differing perceptions of patient symptoms, a phenomenon that likely occurs in the Arab world and needs further investigation.
Gendered Expectations of Pain, Strength, and Expressivity in The Arab World
It has not been explicitly demonstrated that Arab women’s pain is underestimated in the Arab world, yet some aspects of Arab society suggest that it is likely to be the case. First, Arab men are expected to be strong, to be breadwinners, to protect their families, and to suppress their emotions. This masculine ideal suggests that when Arab men finally communicate pain, the expression would be taken more seriously and their experiences legitimized. On the other hand, Arab women are portrayed as nagging and exaggerating in-jokes on social media, which reflects society’s trivialization of Arab women’s experiences and the continuous perpetuation of gendered stereotypes. By extension, Arab women’s pain is probably underestimated, and their communicated symptoms and concerns are likely to be dismissed. It is important to investigate gender stereotypes related to pain and expressiveness in the Arab world in order to further understand and mitigate their consequences. These consequences include differing prescription behaviors by healthcare providers, which we will now look into.
Women’s Pain As Perceived and Treated by Providers
The same stereotyping mentioned above is displayed by healthcare providers in situations that have real-life consequences when patient pain management is on the line. For instance, Schäfer et al. (2016) found that a large sample of clinicians and medical students in the United Kingdom were more likely to judge that women were exaggerating their pain when shown simulations of patients in pain with a brief case history. Female patients rated as untrustworthy were especially more likely to be seen as overstating their pain. Similarly to Zhang et al. (2021)’s study, women were more likely to be advised of psychological treatment while men were more likely to be given analgesics, which is a serious bias in planning care where women end up with the shortest straw. In another study, Prego-Jimenez et al. (2022) linked sexism in health professionals to lower perceived trustworthiness of female patients with lower back pain, and the higher the providers scored on ambivalent sexism, the less likely they were to be willing to provide support for the female patients. The researchers used the Ambivalent Sexism Inventory and the Ambivalent Sexism Toward Men Inventory to asses sexism, however ambivalent sexism towards men did not translate to a lowered standard of care and perceived trustworthiness of their expressed pain. Although this study has a small sample, it constitutes another example of the ways women’s pain is dismissed as an exaggeration and is less likely to be treated with the proper medication. Research in the Arab world has yet to explore this relationship, which constitutes another gap in knowledge to study.
Contextualizing Bias
That being said, it is important to recognize that the presentation of pain in different contexts may influence the degree to which gender bias is prevalent, which constitutes a limitation to the studies discussed above. Bernardes et al. (2011) illustrated that women’s pain is more likely to be dismissed in cases where acute pain is presented, when no distress is communicated, or when male medical students rather than their female counterparts were making the judgments. In the situations where these conditions were not met, gender bias was likely buffered by the communicated length of time in which pain was experienced, or by the clear signs of distress which provide clinical proof and credibility. In another study, gender bias was not clearly recorded. Beach et al. (2021) surveyed medical records in search of expressions used by physicians showing their doubtfulness of patients. It had previously been shown that stigmatizing language in medical records is one of the ways biases can be transmitted, leading to the prescription of less pain medication. In Beach et al.’s (2021) study, the language referring to women that were analyzed was not explicitly stigmatizing, but it suggested that patients were not credible. Although women were quoted more often in the notes made by doctors, indicating a certain degree of disbelief, it could be that they were employed in an attempt to maintain the integrity of the statements in their original form. As explained in the study, evidentials are used to refer to another source when transmitting information, serving to separate the speaker from defending the truthfulness of a statement; they were not used in women’s medical notes more often than they were in men’s. Similarly, judgment words, which express even stronger disbelief of patients were not employed differently when documenting men’s and women’s visits. On the other hand, the study found that Black patients’ records had significantly more frequent usage of quotes, evidentials, and judgment words, signaling a serious bias concerning Black patients’ credibility, which can lead to many barriers such as having trouble trusting physicians and having lowered care outcomes. This example of racial bias leads us to the next theme: Black women and the unique challenges they face.
Women of Color: The Fight to be Heard
Many might be familiar with the infamous experiments conducted in the 1840s by James Marion Sims, “father of modern gynecology”, on enslaved women, without anesthetics, under the assumption that they had a heightened tolerance to pain. He saw the women’s disempowered position as slaves as an opportunity to use them interchangeably, as commodities, in his pursuit of developing surgical treatment plans and tools. However far this era might seem, the present is riddled with inequities and stereotypes that reproduce the same power imbalances in new, and sometimes subtler ways. To this day, Black people are seen as stronger and assumed to feel less pain than they do by others including medical professionals. These beliefs are the remnants of efforts to demonstrate biological differences between Black and White people in the late 20th century in order to justify the inhumane treatment of slaves such as physical punishment.
Bias Towards People of Color and its Influence on Treatment Quality
The current stereotype that Black folks experience lesser pain hinders their access to proper treatment, as they are less likely to be prescribed painkillers and are given lower doses for the same communicated symptoms. In addition, implicit bias reduces the perceived quality of care for ethnically diverse patients. In a study conducted by Blair et al. (2013), physicians who scored higher on implicit bias towards Black and Latinx patients were given lower ratings of care. The study had a large sample size and uses a validated measure for the assessment of implicit bias (namely, Implicit Association Test). However, the standard of care was evaluated through surveys given to the patients, which may be a source of response bias. On the other hand, another study with the same primary investigator found no relationship between physician implicit bias towards Black and Latino patients and lowered treatment intensification or hypertension control. This could be due to multiple factors that buffer the effects of bias, like the long period of time during which the study was conducted, giving physicians the opportunity to adjust treatment and build strong relationships with their patients. Also, the organizations in which the investigation took place are aware of and direct much attention to the treatment of uncontrolled hypertension, especially among Black patients. This, coupled with the integrated approach to care which involves multiple providers like nurses and pharmacists in these establishments are a likely explanation for the lowered impact of racial bias on care. This could be an example of a good institutional design that ensures physician bias has less influence on healthcare. It is important to note, however, that Black patients expressed difficulties in communicating with their primary care providers and reported a standard of care that is less patient centered. This calls for further investigation in a clinical setting where the effects of racial bias are more likely to reduce patient outcomes by being isolated from these buffering factors.
Stereotyping African American Women and Healthcare Implications
With the previously discussed research in mind, African American women face discrimination for their race and gender, in addition to stereotypes such as the “Strong Black Woman,” which prescribes the role of strength, caretaking, resilience, extreme independence, and selflessness to African American women, often as a defense mechanism against the injustices they have survived. This stereotype puts these marginalized women under an enormous load, coupled with the perceived inability to fall ill or take a break. The Strong Black Woman is burnt out, overworked, and does not seek help or proper healthcare, which is a risk to her mental and physical health. This is reflected in the mental well-being of African American women; for instance, the most common cause of suicide in African American women is untreated depression.
On the other hand, African American women are also labeled as aggressive, irrational, and less knowledgeable which characterizes the “Angry Black Woman” stereotype (Malveaux, 1989). This perception reduces the efficacy of mental health services due to misinterpretation of the communicated emotions of African American women. If they are all seen as angry, then the expression of anger is dismissed as cultural rather than personal, effectively silencing the patient and jeopardizing treatment outcomes. The study highlighted the women’s experience of being misunderstood and having to fight the stereotype. Similarly, in a book exploring the healthcare experiences of thirty Black middle-class women in the United States, patients reported feeling dismissed, expressed that their medical needs were not adequately addressed, and had to advocate for themselves in order to receive appropriate care. This finding might be limited to a small sample size and may not be generalizable; however, it provides insight into the barriers faced by Black women in accessing proper healthcare.
The articles surveyed here all have valuable information about the stereotypes applied to Black people and Black women specifically and their effect on the women’s experiences in the healthcare system. On the downside, these studies do not individually explicitly link physicians’ and healthcare providers’ biases and stereotyping to lowered healthcare outcomes and inadequate treatment plans for women of color. This constitutes another gap in knowledge well worth exploring.
The Case of Women Migrant Domestic Workers in Lebanon
In the Arab region, multiple countries rely heavily on women migrant domestic workers (WMDWs), of which Lebanon is a prime example. Although the stereotypes applied to African American Women are unlikely to be generalizable here, due to their historical origin, WMDWs are in a comparable situation to the conditions that led to the emergence of these stereotypes and healthcare inequalities. For instance, the Kafala system is a legalization of modern slavery. According to a qualitative study by Ghaddar et al. (2020), WMDWs’ rights and fair working conditions are made unattainable under Kafala. The migrant workers are expected to always be on standby and work in conditions that are subject to definition by the employer alone, outside of the contract which is rarely translated for the WMDWs in the first place. In addition, WMDWs are confined to the household in which they are employed, are not allowed to leave without supervision, and are often locked inside when employers leave, and their travel documents are withheld from them. These practices are advised by recruitment agencies to avoid escape and subsequent financial losses. As a result, WMDWs are treated as commodities with little regard for their mental and physical well-being. Employers often withhold or threaten to withhold payment in order to discipline WMDWs, which is not supported by interviewed managers. However, some managers went on to justify verbal and physical abuses as means to exert control and ensure that the employees would keep working. Although not explicitly surveyed, these women are most definitely too intimidated to communicate their symptoms should they experience pain or irritation. It is important to further research and mitigate biases toward WDMWs displayed by healthcare providers. Little research has explored the perception of WDMWs’ pain, but it is likely to be belittled, misunderstood, or dismissed given that their treatment reflects such views, which calls for further studies exploring stereotyping and implicit bias towards women migrant domestic workers, inside and outside of the medical field, and the real-life consequences of this prejudice.
Conclusion: Implications for Future Research and Practice
After going over all of these findings, there are two ideas that stick to mind. First, stereotypical beliefs about women’s pain produce quantifiable disadvantages in their access to quality healthcare. Second, specific biases toward women of color are underrepresented in this line of research. Of course, research about physician bias towards queer folks and transgender patients, refugees and immigrants, patients with disabilities, and other oppressed groups has its own merit and value. Unfortunately, I was unable to review these findings due to constraints in the size and scope of this paper.
All in all, these studies show just how important it is to be mindful of validating patients and their communicated symptoms. There is a growing body of research aiming to find the appropriate tools to educate medical staff and students about gender-sensitive care, deconstructing and challenging stereotypes, and improving patient-physician communication and trust. In order to facilitate equal access to quality healthcare for all, it is crucial to expand our knowledge of healthcare provider biases against people of color, Arab women, African-American women, women migrant domestic workers, Arab queer folks, and countless other demographics of patients that are insufficiently represented in the literature.
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