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Still practising

Chris Preece

Tuesday, 29 October 2019

AdobeStock_165097823_mansplaining_blog.jpgBy any definition the life and career of James Barry was an extraordinary one. Having obtained a medical degree from the University of Edinburgh in 1812, he went on to become a surgeon within the British army. He is often credited as the first European surgeon to carry out a successful caesarean section, and took steps to improve sanitations and conditions wherever he was posted, rising to the role of Inspector General of Military Hospitals. He also had something of a reputation for being demanding and difficult, having once been described by Florence Nightingale as a “blackguard”.

The most remarkable thing about this man however is that he was, physically at least, actually a woman. Barry was born Margaret Ann Bulkley and disguised himself as a man in order to enter medical school, an option that simply wasn’t available to women of the time.

That anyone should have to resort to such extremes simply to become a doctor seems extraordinary in these more enlightened times. The world has thankfully moved on, with the spectre of sexism in medicine a thing of the past…

(I’ll pause here, as I fear roughly half the readership might need a moment to stop laughing.)

Obviously, no-one need dress up as a man anymore, but in reality sexism remains depressingly prevalent in the profession. I was reminded of this sad fact by the publication of the BMA’s recent report into sexual harassment within the organisation, which stated that women feel “undervalued, ignored and patronised because they are women”. It goes on to describe sexual harassment and bullying throughout the trade union.

Whilst it’s tempting to assume that this is limited to just a few dinosaurs within the BMA, the more you look, the more apparent it becomes that the issue within medicine is systemic. For instance, the Gender Pay Gap is 17% (33% in General Practice), with roughly 2/3 of consultant positions still occupied by men. Meanwhile a report for the American National Academies for Sciences, Engineering and Medicine, describes staff being sexually harassed by colleagues and patients alike.

A deeper problem is hinted at by the revelation that women are 21% less likely to be invited to offer commentaries in medical journals, when compared to men of similar expertise. A statistic that rises to an even more stark 40% when looking at the most senior authors. If women are under-represented in research, to what degree might women be ignored in our understanding of medicine itself?

Again, historically, medicine has not always been a discipline that has surrounded itself in glory in this respect. Aristotle for instance observed that “the female is, as it were, a mutilated male”, whilst Aretaeus of Cappadocia wrote in the 2nd Century AD that the womb is “like an animal within an animal” forever moving “hither and thither”. (His observation that this creature “delights in fragrant smells, and advances towards them” presents some particularly amusing mental images.) 

The idea of the Wandering Womb subsequently gave way to the notion of “hysteria” as the standard medical explanation for anything in a woman that didn’t quite make sense, followed by a brief pendulum swing towards demonic possession and witchcraft, before swinging right back to hysteria again.

Whilst “hysteria” is happily now also a diagnosis of the past, that tendency to pigeonhole symptoms in women that don’t conveniently fit our established models as somehow not physical remains. For instance we’ve known for some time that women are less likely to have “classical” symptoms when they experience a heart attack - yet according to the British Heart Foundation they remain 50% more likely to get the wrong diagnosis, with their symptoms often being dismissed as anxiety. This isn’t just a problem with human physicians, as it also appears to be the preferred approach of Babylon Health’s Symptom Checker. This reportedly advises that a 59 year old female smoker with chest pain is most likely having a panic attack, but a man with exactly the same symptoms should go to A&E. (Babylon, for what it’s worth, are keen to point out that this position “is, in fact, correct”, citing lower statistical risk of heart attacks in women, and higher incidence of anxiety disorders. “If you hear hoofbeats, don’t think zebras, it’s probably horses” they implore us. Which is, of course, sound advice – but then zebras aren’t particularly known for killing you. Heart attacks are.)

Perhaps the problem here is that medicine, like Aristotle, still regards men as the norm, and women nothing more than a curious deviation from it.

For instance, a study looking at anatomy textbooks from 1890 to 1989 found that depictions of the human body consistently show male anatomy, with less than 10% showing women. (Meanwhile this Twitter thread detailing the bizarre use of pictures of women unnecessarily stripped to their underwear to illustrate an Orthopaedic textbook, shows you how badly people can get it wrong when they do remember to include women.)

Women aren’t just under-represented when depicting bodies though, they’re under-represented in understanding them too. One American report looking at the representation of women in medical research points out that just 1/3 of cardiovascular clinical trial subjects are female, and of those that include women at all, only 31% actually bother to report the outcomes by sex.

Meanwhile, whilst women represent nearly half the people in the world living with HIV, they represent only 19.2% of participants in anti-retroviral studies, and 11.1% of studies looking for a cure. The differences between the sexes are evident at even the cellular level, and yet there is so little time spent looking at what these differences might mean, that entire books have been written simply detailing what we don’t know.

Huge chunks of our understanding of the human body are, in fact, just understanding of male bodies. This wonky data then gets fed back into our education, our practice, and yes, our exciting new “factually correct” computer algorithms. 

Looking at all this, I’m suddenly aware of the true genius of James Barry. This was someone who realised that, sadly, the only way to succeed in the medical establishment as a woman was to pretend to be a man - and yet conversely that he could escape detection precisely because, it turns out, on all but the most superficial level, medicine generally assumes all women are men anyway.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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