One thing the SciMoms have learned covering vaccines and alternative medicine is that only the most extreme fringe believes wholeheartedly in conspiracy theories and pseudoscientific arguments. Most people with doubts about mainstream medicine don’t trust doctors and medical research because of historical and current mistreatment of marginalized people. We asked Jill Delston, PhD, the author of Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care, to explain Medical Sexism and how it contributes to distrust in the first place.
If you have ever been told you cannot get a prescription refill on your birth control pills until you come into the doctor’s office for a Pap test; if your experience in the labor and delivery room involved medical professionals overriding or ignoring your expressed wishes; if you have ever received a misdiagnosis or delayed diagnosis due to a physician not listening to or believing your symptoms, you may have experienced “medical sexism.”
Medical sexism uses medical means or medical ends to uphold, assert, or achieve a gendered hierarchy of femaleness or femininity subordinated to maleness or masculinity. Patients who experience medical sexism are often more vulnerable to harm, have less protection of the law, and face a reduced capacity to fulfill their preferences than others. That’s because medical sexism often includes violations of consent and choice as well as failures to follow best practices in standards of care. Medical sexism is both severe and widespread, impacting all sorts of patient care. Medical sexism is also stealthy, making it difficult to identify and eliminate. In the worst cases, medical sexism kills.
This definition of medical sexism can impact all genders because the hierarchy of maleness or masculinity over femaleness and feminity can also harm non-binary individuals and men. For instance, a trans man can be denied access to needed medical care as the result of a sexist practices just as a cis woman can. The definition doesn’t hinge exclusively on the sexist beliefs or intent of any single perpetrator— it includes impacts of medical practices, behavior of medical providers regardless of motive, systems like policies and regulations, and institutions like doctors offices and hospitals. There doesn’t need to be explicit oppression or discrimination for medical sexism to occur because the same act can have different impacts on different people—a mere inconvenience to one person might be oppressive to another who has, say, an hourly job, a disability, or lacks of other privileges. An intersectional approach to medical sexism, which includes intersecting hierarchies like racism, xenophobia, classism, ageism, and ableism, is crucial to understanding its impacts.
Too often, medical sexism is belittled or dismissed, and we are told that while it may have been true in the doctor’s office decades ago, it no longer exists today. This strategy of denial and gaslighting, often used to protect oppression and discrimination, needs to be identified and addressed head-on. And medical sexism must be named, along with those other hierarchies like racism and classism in medicine, because we can never eliminate an injustice unless we call it what it is.
Medical sexism in contraception care
Reproductive health is rife with medical sexism, both historically and today. For instance, when doctors ask patients to undergo pelvic exams or cancer screenings before they will renew birth control prescription refills, they are engaging in a paternalistic denial of patient preference. Requiring such tests every year contradicts the scientific evidence that suggests that yearly testing is only necessary after a positive test, which is why institutional recommendations say patients ages 21-65 should only receive a Pap test every 3-5 years. Yet doctors still deny birth control refills in service of testing at incredibly high rates.
For instance, a 2020 study in the Journal of the American Medical Association concluded through patient surveys that millions of girls and women ages 15-20 received unnecessary Pap tests and pelvic exams in the previous year. In fact, major medical organizations like the American College of Obstetricians and Gynecologists (ACOG) recommend against routine Pap tests for patients under 21 years old.
When it comes to routine pelvic exams, whether or not they should be done is more controversial than ever. The United States Preventive Services Task Force recommends against routine pelvic exams, citing insufficient evidence for the practice, though ACOG still recommends them for healthy patients. Yet, no major medical organization recommends yearly Pap tests or pelvic exams for the average patient and no major medical organization recommends tying birth control to cancer screenings. Demanding these added tests breaches a duty to the patient by withholding ongoing and necessary medical interventions in violation of the standard of care.
Withholding birth control in service of these exams can also rise to the level of medical malpractice when it causes injury. Hormonal birth control is the most popular form of contraceptive care, and in a country where the maternal mortality rate is high and rising, denial of contraception is a serious harm. About half of all pregnancies in the United States are unintended, and reproductive planning is incredibly central to individuals’ lives. Many patients also rely on hormonal birth control for the treatment of a variety of conditions, including endometriosis, and the prevention of medical conditions like ovarian cysts. Ironically, hormonal birth control can even reduce the risk of certain cancers that pelvic exams screen for, like ovarian and endometrial cancer, meaning that withholding hormonal birth control in service of cancer screenings can actually increase the risk of certain cancers.
Discontinuing or threatening to discontinue ongoing and needed medical care —whatever the reason—is generally viewed as impermissible in other medical contexts. For example, we don’t see an epidemic of doctors withholding dialysis treatments from patients experiencing kidney failure until they undergo a prostate exam, even if the doctor thinks a prostate exam is a good idea. Similarly, doctors do not generally require patients to receive a colonoscopy before they will release a prescription for erectile dysfunction. If doctors were to threaten care in this way, they would be subject to concerns about medical malpractice and medical negligence. In analogous cases, that is, patients do not need to undergo unindicated and unrelated medical tests to continue health care. Yet, it is incredibly common in reproductive care primarily aimed at women.
In the contraception case, no fetus exists, which allows us to focus on the often paternalistic and infantilizing treatment of the adult patient. In other cases of reproductive health, like abortion, labor, and delivery, a fetus is present that purports to explain or justify overriding the preferences of the pregnant person. But patients do not lose their rights when pregnant, and a fetus can never justify overriding a pregnant person’s autonomy. Acknowledging that the same attitudes, treatment, and behaviors are present in birth control cases, when no fetus exists, underscores what’s going on if and when a fetus does exist. The common thread is not a fetus or some other explanation of why patient rights must be violated. The common thread is the gendered treatment, which undermines patient rights and preferences and upholds the gendered hierarchy that characterizes medical sexism.
In pregnancy and birth
Medical sexism also occurs in pregnancy and birth. Consider bed rest during pregnancy. Doctors are still likely to prescribe bed rest today, despite the fact that it increases risks of preterm birth, morbidity, and mortality. It doesn’t achieve any particular health aim, but it fits societal expectations of women belonging in the home and sacrificing their own autonomy and mobility to motherhood. In fact, 20% of pregnant women are prescribed bed rest and more than 90% of doctors prescribe bed rest when issues of preterm birth arise. Yet, no evidence recommends bed rest for any condition and never has. On the contrary, bed rest is associated not just with blood clots and loss of bone density, but also with depression and financial peril. Just as in the contraception case, controlling pregnant people’s behavior takes precedence over the lack of evidence recommending it and the strong evidence suggesting it be discontinued. In other words, medical sexism, not medical science, explains this practice.
A similar phenomenon exists in C-sections during labor and delivery. C-sections can be a crucial and sometimes life-saving intervention. Still, a third of all births in the United States occur by C-section, even though C-section rates above about 10% are not medically indicated. Maternal mortality is nearly four times higher in C-section births than vaginal births, complications are 80% higher, and neonatal mortality is two times higher. The maternal mortality rate in the United States is the highest in the developed world at 17.4 deaths per 100,000 live births, but, due to systemic racism, varies drastically by race, with Black, American Indian, and Alaska Native women experiencing a maternal mortality rate twice the national average. Just as telling? A significant percentage of those who have received a C-section report they had no choice. By contrast, those who have not received a C-section may have wanted one and had their requests ignored, which is also a problem.
Beyond reproductive health, pregnancy, and birth
Medical sexism is not limited to reproductive health, pregnancy, and birth. Thirty years ago, Bernadine Healy, who was then the first woman to serve as director of the National Institutes of Health, described a crisis in the disparate treatment of women in heart disease in an editorial in The New England Journal of Medicine. Around the same time, author, philosopher, and activist Angela Davis wrote about disproportionate cardiovascular disease and outcomes impacting Black women in her book, Women, Culture, & Politics. It’s concerning that not enough has changed since then. Today, heart disease is the leading cause of death in women, accounting for more than 1 in 5 deaths overall. Yet studies show doctors are still uninformed and misinformed on cardiovascular disease in women and regularly fail to follow evidence-based standards of care. A significant portion of young women are sent home from the hospital during a heart attack. Women are similarly worse off when it comes to diagnosis, care, outcomes, and research in heart disease. This ongoing crisis of poorly-managed cardiovascular disease in women is medical sexism at play on the systemic level—it includes individual doctors routinely engaging in negligent care, hospitals contributing to the poor management of cardiovascular disease in women, as well as missing or misleading research.
Sexist medical care is even found in organ transplantation. Women fare worse at each step of their medical care leading up to needing an organ transplant: from diagnosis and referral to time spent on a waiting list to post-transplantation care. Men have received more than one and a half times the share of organ transplants in the United States as women overall. If we break these numbers down by the type of organ, we see gender disparities across the board— men receive more kidney transplants, heart transplants, and lung transplants.
Medical sexism also breeds doubt. Feeling dismissed, ignored, or violated in the doctor’s office can lead to skepticism of health care providers and even of science generally. If individuals can’t find a doctor they trust who takes their symptoms seriously—and who doesn’t bring up memories of past trauma—they may turn to unqualified providers. The purveyors of anti-vaccine rhetoric, naturopathy, and other pseudoscientific practices can capitalize on the vulnerabilities and desperation of those who have been mistreated by the medical field.
Addressing medical sexism
Understanding the empirical facts through the lens of medical sexism is crucial because looking at the symptoms of prejudice— such as C-section and organ transplantation rates— without identifying the cause, has left individuals open to gender discrimination and the violation of their rights in other areas of medicine. Making hormonal birth control available over the counter, reducing episiotomies (an incision made in the perineum to enlarge the opening for a baby to pass through), better diagnosis and treatment of autoimmune disorders, and other attempts to mitigate medical sexism all work to improve medicine, but in a piecemeal fashion. We should address each individual problem while recognizing that they are connected and systemic.
In addition to acknowledging, naming, identifying, and addressing medical sexism in the face of denial and gaslighting, we should amplify voices speaking out about it, share our platforms, and defend credible accounts where possible. We’re stronger together and we are stronger when we speak out. We can also address medical sexism in the courts, the legislature, and the executive branch with our votes, our activism, and our actions.
One thing is clear: structural injustice requires structural change. No matter how informed and prepared we are for conversations in the doctor’s office, no matter how thoroughly we shop around for the right doctor and establish our boundaries, no matter how robust and collaborative a doctor-patient relationship appears to be, our rights can still be denied, our symptoms can still be dismissed, and our pain can still be overlooked. To tell individuals that they can solve these problems on their own is not only blaming the victim, as if medical sexism is only perpetrated against those who didn’t try hard enough, but also leaves too many behind: not everyone is empowered to advocate for themselves.
Jill B. Delston is an Associate Teaching Professor of Philosophy at the University of Missouri-St. Louis. She is the co-editor of Applied Ethics: A Multicultural Approach (editions 5 and 6). Her book is entitled Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care (Lexington Books, 2019). She is the happy mom of two precious kiddos.