Why do women and men face different risks of disease? Can these differences be explained by biology, or by a complex set of social factors based on stereotypes? "Deconstructing prejudices and understanding physiopathological variations are essential if we are to ensure that patients are treated fairly," points out Angèle Gayet-Ageron, associate professor in the Department of Community Health and Medicine and staff physician in the HUG Division of Clinical Epidemiology. "However, this issue is still very much absent from physicians' training, and is of little concern to many healthcare professionals, for whom even the definitions of sex and gender are not clear."

Sex and gender are in fact distinct concepts: sex relates to the biological, and in particular the genetic and hormonal bases that define the anatomy of the external genitalia, whereas gender is a social construct that reflects individual gender identity and expression, and the role assigned to individuals by their family, the society in which they grow up, the education they receive, and politics. "It is also important to emphasise that both sex and gender are concepts that need to be understood as a continuum, rather than as binary parameters," stresses Melissa Dominicé Dao, lecturer in the Department of Community Health and Medicine and staff physician in the HUG Division of Primary Care Medicine. "Sexual development, in particular, is subject to infinite biological variations, and neither sex nor gender determines an individual's sexuality."

A national initiative

In 2019, the Swiss Gender Health Network brought together several research groups across Switzerland with an interest in these issues from different angles - historical, ethical, medical, etc. Funding from SwissUniversities made it possible to strengthen the design and implementation of certain initiatives in a national interdisciplinary project. The objectives were to define a minimum common curriculum and to create a web platform for sharing teaching materials. "Completed last year, this project led to the creation of the GEMS platform, which compiles all the teaching materials created in the various Swiss institutions involved in the project (faculties of medicine and the University of Applied Sciences of Italian-speaking Switzerland, SUPSI) and makes them available to all members. The project has also given rise to the Swiss Society for Gender Health, whose mission is to promote the integration of sex and gender in health, teaching, research and regulation, using a multidisciplinary and interprofessional approach".

This initiative led to the creation of the Medicine, Gender and Equity Group at the UNIGE Faculty of Medicine in January 2020, which also adopts a plural approach with physicians, teachers, biologists, but also specialists in ethics, anthropology, public health and students.

"We can analyse gender and sex from a number of different research angles: basic, clinical or public health", explains Angèle Gayet-Ageron. "For the moment, we are concentrating on two main objectives: to teach the importance of sex and gender in patient care, by better integrating these concepts into the medical curriculum, and to address issues relating to sexist and sexual harassment. From these two elements flow many others: the teaching of medical consent, the obstacles to women's medical careers, and more generally the intersection between gender and other factors of inequality such as age, ethnic origin, socio-economic status and disability".

The first step was to identify the training objectives in relation to the PROFILES objectives, in order to assess which of them were linked to the issue of sex and gender. The team then assessed whether and where these objectives were being taught, and what was missing, to propose new courses or add these dimensions to existing courses.

A relentless analysis of clinical vignettes

For her PhD thesis, Sara Arsever, staff physician in the HUG Division of Primary Care Medicine Department, worked on gender bias and stereotypes in clinical vignettes - the basis of teaching in the Masters years - in internal medicine, primary care medicine, psychiatry and paediatrics, to see how men and women were presented as patients, relatives and medical staff. "The findings were distressing! In paediatrics, no father is mentioned  consulting alone with his child; the vocabulary places parental responsibility on mothers. Generally speaking, the people close to the patient are almost always women: the wife, the daughter, the mother or even the daughter-in-law," explains Melissa Dominicé Dao. "On the patient side, it's no better. Men appear as bank executives or lawyers, while women are part-time secretaries or hairdressers. Gay men only consult for sexually transmitted infections, and never for any other reason. In practice, however, physicians see all kinds of patients for all kinds of problems. Anchoring these stereotypes in their minds is bound to distort their analysis".

The same problem applies to the representation of healthcare professionals: 86% of physicians are men and 98% of nurses are women, despite the fact that 63% of medical students are women. "Here too, we are distorting the picture by under-representing women in managerial positions and by basing the Care function on essentially female representations."

Learning to report harassment

One of the first successes of the Gender and Equity in Medicine Group was the introduction of a compulsory course for medical students on how to deal with harassment. This course, which takes the form of theatrical expression, has already won many awards. Workshops have also been launched for tutors. "A recent study showed that 25% of physicians experienced harassment but did not know how to react. We also need to encourage the profession as a whole not to let these acts go unchallenged, to stand up for the victims and to provide easily applicable tools."

While the Group's coordinators are delighted with the support they have received from the Faculty - they have, for example, presented their work to the College of Professors, where it was very well received - there is still a lot of resistance. "It's sometimes a question of generation, but also, and this is more worrying, the result of political polarisation. There is a fear of a backlash, which could also take the form of a withdrawal of funding for research and teaching on sex and gender."

However, the energy of the younger generation is a source of hope. "We would like to launch a mentoring programme to encourage young female professionals and train them in leadership skills, and are following student projects with great interest, through the CLASH campaign on sexist attitudes, for example, or highlighting historic female figures in medicine by renaming the Faculty's auditoriums."

Prof. Angèle GAYET-AGERON
Department of Community Health and Medicine & Division of Clinical Epidemiology, HUG

Dr. Melissa DOMINICÉ DAO
Department of Community Health and Medicine & Division of Primary Care Medicine, HUG