‘Gender issues can be perceived as threatening in medicine’

Why it matters. Joëlle Schwarz joined Unisanté in 2017. There, she develops research programs, teaches courses at the Unil School of Medicine, leads workshops against gender-based violence and harassment, and tracks gender bias in clinical practice. Awareness of the importance of her work in the medical world is slow to germinate, but essential.

Who are we talking about. The woman from Lausanne carries a multitude of projects on her shoulders. Upon meeting her at a downtown café, listing her projects, programs and conferences takes a good 40 minutes. She is not alone at the helm: she co-directs the Medicine and Gender Unit of Unisanté with Professor Carole Clair. A team of a dozen people also assists them.

The fight against health inequalities is not new. Following feminist movements, several universities have explored the subject in greater depth, before letting it fall into oblivion for lack of real interest or funding. In Lausanne, the FBM has been supporting the Medicine and Gender project since 2011. A dedicated Commission was also created in 2017, the same year Joëlle Schwarz joined Unisanté, armed with a master's degree in social sciences and a PhD in epidemiology.

The constant attention that Unil and the FBM pay to this theme now makes the institution a pioneer in this area. Joëlle Schwarz:

"At the Swiss level, Lausanne is clearly ahead of the other universities. However, the major achievements are recent: it is only since 2019 that the development of projects and research has gained momentum. Just like in Zurich.

But the FBM is not exactly a pioneer at the European level. Gender issues have long been part of university programs in the Netherlands and Germany. But it is true that in France, there are very few programs in medicine and gender."

The equality prize of the FBM awarded on June 14, 2021 is thus as much a recognition as a signal of encouragement to continue these efforts. This includes launching research programs, federating the country's universities around gender and discrimination and pooling resources to develop a "real institutional force," Joëlle Schwarz emphasised.

Marc Robinson-Rechavi, associate professor in bioinformatics at the Department of Ecology and Evolution at the University of Lausanne, explained the choice of Joëlle Schwarz to receive the award:

"This award is given to Joëlle Schwarz in recognition of her investment and essential contribution to the teaching and study of the influence of gender on health and disease. Joëlle Schwarz has an unusual profile at the FBM, as she has an initial training in social sciences, followed by a PhD in epidemiology.

The Medicine and Gender Unit of Unisanté is a leader in this important topic in Switzerland: Joëlle has been a member since 2017 and co-leader since 2019. Her dynamism and investment have been and remain indispensable to the success of this unit and to the progress of equality in our faculty."

Medicine and gender, a threat? Just the tip of the iceberg of this vast subject, at the interface of the bio-medical and social sciences, the issue of women doctors is often addressed. But it is not this aspect of equality that the epidemiologist is working on. Joëlle Schwarz explains that it is "not always easy to bring this subject up in an environment that is not necessarily sensitive to gender issues. It can even be perceived as threatening in the medical environment. It takes energy to raise these issues. The prize therefore rewards this action, shows that this work makes sense and that it is recognized by the FMB".

What frightens the medical community is a stereotype that is quite well-rooted according to the specialist:

"Gender issues are often seen as an activist and ideological cause. Some people wonder how you can mix elements as scientific as medicine with elements as ideological as gender issues.

This is obviously not my point of view at all. Physiologically, my work makes sense, but there are still people who don't understand what we do and how we articulate gender and medicine. They think we're just talking about women's place in medicine."

When her action is not understood, it can be reduced to:

• Its sole aspect of fighting for the recognition of women's place in clinical and academic settings or

• Assimilating gender to trans-gender issues.

But the work and projects carried out by the Unisanté Gender and Medicine Unit are neither militant nor ideological. They are physiologically and scientifically justified, and also help to better train the doctors of tomorrow. The main lines of action developed over the last three years are many and concern training, research and awareness of gender biases.

• Gender measurement index. This project, financed by the Swiss National Science Foundation (SNSF), is called Spark. Joëlle Schwarz:

"Unisanté is developing methodological instruments to measure gender in clinical and epidemiological research. This is useful because right now, the male-female variable is used, which does not mean much because, when we stick to this binary division, we do not know whether we are talking about hormones, chromosomes, gene expression or whether we are observing gender-related social factors.

In the long run, we plan to propose a sort of toolbox for researchers to measure gender in their studies. These indicators will be made available to researchers."

• Prevention of sexism and harassment. This interactive training on the prevention of sexism and sexual harassment enables future doctors to identify problematic situations. Joëlle Schwarz:

"Mandatory for third-year Bachelor of Medicine students, this training has existed for two years. Through theatre, students have to take on the roles of victims or witnesses of sexism or sexual harassment. It is up to them to find solutions to get out of these situations. This approach is very important in order to involve men in these recognition dynamics. For some, the training comes as a revelation. They become aware of the prevailing sexism and realize how they could act in the future."

• Gender issues in clinical practice. Medical master's students are educated since 2019 to identify their own gender biases when caring for patients. Joelle Schwarz:

"All medical students (240, ed.) spend a week in a policlinic where they do general medicine. They follow assistant doctors and see patients all week. At the end of the week, in groups of five students, they present a clinical case that they have seen in front of a chief of clinic. The idea is to teach them clinical reasoning and how to ask questions during the anamnesis, how to perform a physical examination, how to make a differential diagnosis. Students thus learn the steps of systematic reasoning.

We have added a gender module to this teaching. We attend these teachings and at the end of the exercise, we ask them to redo all of this clinical reasoning by asking the question, "If the patient had been a female patient, or vice versa, what would have been different in the management?" This allows us to discuss possible reasons for caring for a female patient differently from a male patient. We assess whether there are clinical reasons to do so. It also allows us to identify gender biases in care.

Among common biases, we note that there are already gender-based differences in the questions asked. For example, students tend to explore psychosocial aspects more easily in the case of women and the professional sphere more easily in the case of men. Once the biases are identified, it becomes possible to control and correct them."

Not just a women's issue. These different approaches allow for better overall care of both male and female patients. Various studies show that women are not the only ones who are medically discriminated against. When men suffer from anorexia, depression or osteoporosis, they are under-diagnosed in the same way as women are when they have cardiovascular problems or when they have to deal with pain.

The global approach developed by Unisanté thus matters for both men and women. It is therefore a question of equality. However, men have difficulty in getting involved in this field, as Joëlle Schwarz regretted:

"It's a bit frustrating to see that the doctoral students who come to us are always female. So to make it clear that we are addressing everyone, we are always careful to use examples of male discrimination and care in favor of men, even if the vast majority of inequalities are in favor of women.

It's all the more important to show discrimination on both sides, as it can help avoid missing certain diagnoses."

Her goal: to show that medicine and gender do not equal medicine and women.

Limitations. While the specialist notes an evolution among students, it is still too early to assess the efforts made over the past three years. But there is still hope to "reduce inequalities in medicine based on stereotypes, in the medium term. I also hope that gender issues will be much more recognized as a problem affecting both men and women. I also like to imagine that men will someday realize that the current healthcare system is not in their favor either, and take up these issues."

Le Prix Egalité de la FBM a été remis pour la première fois en 2019.

2019: Association Clash (Romaine Delacrétaz, Eva Piccand, Ilire Rrustemi et Léa Schilter)

2020: Béatrice Desvergne

2021: Joëlle Schwarz

---