I recently had to find a new Primary Care Provider. I didn’t need one for anything in particular— just insurance purposes really— so I found a convenient group of physicians and gave the organization a call. After the formalities (patient name and birthdate and insurance) I was met with the question: “Do you prefer a male or female provider?.” While, perhaps, this question doesn’t come across as particularly remarkable, it indicates a cogent implication in the treatment of gender by the medical community, specifically regarding patient-provider relationships. First, it indicates that the patient notices a marked difference in their treatment from a male provider and a female provider (and vice versa). Second, the question implies that these are the only options for providers: Male or female. This indicates that the patient-provider relationship is, by this question alone, defined by the gender binary. For those (both patient and provider) who fall outside of this binary, the process of receiving healthcare is initiated with a question that may not have a clear answer, or more importantly, a comfortable one.
This question, “Do you prefer a male or female provider?” implicates a broader point that needs to be analyzed: how do medical bioethics and gender intersect? And perhaps, an even deeper question— how might gender contribute to medical specialties that deal less with our anatomy, or more with our psyche? Our cultural and societal education has given us the tools to understand, for instance, the motives for a heterosexual, cisgendered woman identified person preferring a female obstetrician. However, how do these preferences, and the resulting implications, translate into the vulnerable lobes of the brain? Who do we prefer to lay our souls bare to, and moreover, who do we trust to sew together our fragmented emotions and personalities?
A plethora of scientific articles arise in considering the physiological differences in neuroanatomy between male and female born persons. There is less scientifically efficacious information on how these differences manifest in the forms of psychiatric illness. Moreover, there is even less information regarding the psychiatric experience of transgendered, nonbinary, or intersex individuals. In fact, the diagnoses in the psychiatric manual (the DSM-5) pathologize the experience of people with non-conforming gender identities (Lawrence 1263). Alongside personality disorders, eating disorders, and depression, is the term “Gender Dysphoria” . In their 2015 article, Anne Lawrence writes that, from the very basis of the naming of this psychiatric illness is incoherent:
“ The DSM-5 conceptualization of GD as reflecting an incongruence between gender identity and “assigned gender” necessarily renders the new diagnostic criteria semantically incorrect as written, because it is biologic sex, not gender, that is recognized—and is “assigned” only in accordance with that recognition—at birth”.
(Lawrence 1264)
Lawrence is referencing the negligent and confusing use of psychiatric diagnostics to define the experiences of those whose gender identity’s doe not align with their assigned sex. This is evidence of how medicine and gender identity are still at odds, and consequently, patients are barred from access to empathetic care because psychiatrists are not given the proper language and tools to treat them (1266).
The pervasive concomitance of transgressive gender expression and its association with mental illness originates in the hallowed origin of western, industrial medicine. As class systems arose, germ theory appeared, and medicine became a regulated community of shared academic research, gender and medicine became inextricably wound through academic, societal, and cultural influences. Most notably, was the association between women’s ‘fragility, delicacy, and femininity’ and a predisposition to ‘nervousness’, or mental illness (Mitchell 106). In addition to and as a result of the assumed innate predisposition of women to mental illness, the 19th century rhetoric on psychiatry was charged with gendered language and theories. Weir S. Mitchell was a notable psychiatrist in the 19th century. Mitchell was famous for being the proprietor of “The Rest Cure” and “The West Cure”, which were prescribed, respectively, to female and male patients experiencing psychiatric breakdowns (Will 293). “The Rest Cure” was a psychiatric treatment prescribed to women where they were bed-ridden until they had healed, disallowing tasks as simple as writing or reading for fear it might further deteriorate their wellbeing (Will 293-294). “The West Cure” was a psychiatric treatment prescribed to men, where they would be sent out to the infamous dude-ranches of western America and were recommended to engage with nature and escape their responsibilities at home (Will 293-294). In his 1872 book Wear and Tear Mitchell discusses the importance of understanding both male in female psyche, writing:
“In studying this subject, it will not answer to look only at the causes of sickness and weakness which affect the male sex. If the mothers of a people are sickly and weak, the sad inheritance falls upon their offspring, and this is why I must deal first, however briefly, with the health of our girls, because it is here, as the doctor well knows, that the trouble begins. Ask any physician of your acquaintance to sum up thoughtfully the young girls he knows, and to tell you how many in each score are fit to be healthy wives and mothers, or in fact to be wives and mothers at all. I have been asked this question myself very often, and I have heard it asked of others. The answers I am not going to give, chiefly because I should not be believed– a disagreeable position, in which I shall not deliberately place myself. Perhaps I ought to add that the replies I have heard given by others were appalling”
(Mitchell 109)
The beginning of this quote indicates that the the male sex and female sex are intrinsically different, and therefore there are different reasons for providing them with treatment. Moreover, Mitchell explicates that this research is important because women are intended to be wives mothers, and their health begins in adolescence and childhood. If they or their mother’s are sick, argues Mitchell, they cannot fulfill their wifely and motherly duties. Mitchell is not concerned with the quality of life of women, or with their general well-being. Rather, his theory implies that the only driving force behind providing psychiatric care to women is so they can be subservient to men– through their provision of children and marriage. Additionally, the cure for women is to take away their power and make them reliant on others, while the cure for men is to absolve them of their responsibilities and send them on a journey of self-discovery. This implies that, for men, the problem is external while for women, the problem is internal. Again, this reinforces the gender binary, upholds the oppression of women through medicine, and indicates that it is not the negative and painful experience of being mentally unwell that is important– rather the limitations this puts on their ability to serve others.
Charlotte Perkins Gilman responded to the efficacy of “The Rest Cure” in her 1892 short story “The Yellow Walpaper”. The book documents the experience of the main character, a woman who is taken away by her physician husband to a country side house and placed on the rest cure (Gilman 1-2). The main character has recently had a baby, and there are numerous references to her inability to care for the child throughout the text (Gilman 4-7). Additionally, the story documents the woman’s penchant for creativity, and her husband’s egregious control of her ability to artistically express herself by removing all texts, journals, and other abilities to engage in the creation and consumption of knowledge (Gilman 2-8). The story resolves in the undoing of the main character’s mental well being, as she envisions the woman she sees living in her walls breaking out, and proceeds to crawl around her room. Her husband comes in to see her, and faints after sighting her (Gilman 10). This story is an important contextual response to Mitchell’s psychiatric theory, because it embodies the literary response of a woman writer to the psychiatric practices of a predominant male doctor. It is important that Gilman documents the lack of efficacy of the rest cure through the short story, “The Yellow Wallpaper” because it functions as an important and reliable patient narrative, in a time when the patient narrative of women in psychiatric care were not prioritized or published.
As the subjugation of women was a common practice in society, this translated to patient-provider relationships. It was impossible for women to be empowered by their male physicians because they were societally subordinate to them, and occupied a role that seemed impossible to be equally occupied by women implying that this anatomical authority was intrinsic to maleness and not to humanity, itself. This implicated the patient-provider relationship between male physicians and female patients to become hierarchical— where the male physician was the authority over the female patient’s body on a basis of access to knowledge alone. Furthermore, as women were unable to access healthcare professionalism, the medical community was dominated by male physicians. This meant that all opinions, research, and medical knowledge originated from the understandings of men— even that knowledge regarding things uniquely female.
The transgression from this societal expectation is examined in the novel, Doctor Zay, by Elizabeth Stuart Phelps. Doctor Zay is featured in the novel as a woman physician in the 19th century (Phelps 35-43). Doctor Zay works to treat the nervous breakdown of a man, Waldo Yorke, after he suffered from fainting on a trip up the coast from Boston to Maine– at the time; fainting was a symbol of mental illness (Will 296). Doctor Zay is, at first distrusted by the man who expresses his surprise that his physician is a woman and proceeds to question her education and credentials (Phelps 45). Eventually Waldo trusts Dr. Zay to provide him with care, but proceeds to fall in love with her. Doctor Zay manages to maintain her patient-provider boundaries, and refuses his advances (Phelps 170). However, eventually, after Waldo is no longer Doctor Zay’s patient, she proceeds to break down crying after his incessant advancements and accepts his proposal (258). At one point, the dialogue between Waldo and Mrs. Butterwell (Waldo’s host) clarifies the societal explanation for why Waldo cannot manage to receive care from a woman physician without developing feelings for her:
“And when you think of having a woman like Doctor to turn to, sharin’ the biggest cares and joys a man has got, not leanin’ like a water-soaked log against him when he feels slim as a pussy-willow himself, poor fellow, but claspin’ hands as steady as a statue to help him on, and that hair of hers, and her eyes, for all her learning!”
(Phelps, 180)
This quote clarifies that Phelps, as a woman writer, was using the transgressive relationship of a woman physician and male patient to clarify that it was not the woman who was internally limited from becoming a doctor, but rather was limited by men and society from being a physician. This book represents the incapability for men at the time to feel disempowered by the authority of women in medicine, and how intimacy could be used as a method of control in response to this.
It should be noted that stereotypical gendering of medical professionals has another origin within the community of healthcare regarding the clinical and practical difference between doctors and nurses (Hollup 756). Outside of religious institutions, nursing’s origins are in acute crisis care— in times of war, when men were recruited to fight against enemy troops, nurses were young women who were called upon to undergo training in order to care for wounded soldiers (Hollup 756-757). While this relationship— between patient and provider— is unique in its lack of male medical authority, it is based on the need for women to serve men. This is important to note as the profession that prevails today, is based on the subjugation of women even in roles of medical authority and continues to contribute to the stigma of going into nursing. Stigma is further contributed to by the medical hierarchy, where physicians have medical authority over nurses (Hollup 756, 758). At the advent of secular nursing, physicians were still predominantly male and had medical authority over nurses; Interestingly, nursing is still predominantly female (Holup 756-758). However, male nurses tend to gain promotions and raises more quickly than their female counterparts (Holup 759). The pervasive orientation of nursing as a “female” profession, again, indicates that nurses are not able to exist outside of the gender binary. This allows males in nursing to gain unjust preference and authority, as they benefit from societal associations of males and authority which mean they get to gain unfair precedence over their female counterparts. Additionally, the gendering of the nursing profession explicates a medical scenario in which females are interested in obtaining medical knowledge, but do not have equitable access to becoming a physician, and therefore needed to claim and invent a new medical role which fulfilled a gap in care but continued to occupy the societal subjugation of women in medicine.
While, thankfully, the glass ceiling of the medical field has been broken by women physicians for a short but significant amount of time, the knowledge base and bioethical origins of the western medical community still has deep roots in its original male-dominated propriety. The same is true for physicians and patients of color as well as those with indigenous heritage— they are deeply disenfranchised because of the disproportionate and unjust discrimination of the medical community against them. While the topics of race and gender in bioethics are not mutually exclusive, they cannot be discussed in summation as part of this analysis, and therefore cannot be included ethically. To clarify, there is such excessive intergenerational trauma inflicted upon communities of color– especially black communities– by the medical community, that to touch on this subject would be allocating a disproportionately small segment of this analysis to an exceptionally large and current issue. It should be noted, that black patients and other patients of color can experience different and exceptionally traumatic medical encounters as a result of racism and white supremacy being ingrained in the American medical system. Additionally black individuals and individuals of color have had, similarly to women, and perhaps more pervasively, a lack of access to obtaining roles of medical authority. As I proceed with my analysis this should be taken into consideration, as I am unable to reasonably include the rich and incredibly profound history of race and medicine in this forward without going far beyond my limited page allocation. Furthermore, it should be noted that I am primarily focusing on white narratives, which exclude the lived experiences of individuals of color and therefore this analysis can only fully reflect the experiences of white patient-provider relationships.
