35 The healthcare professions as gendered

Across the entire field of the sociology of the professions, the subject of gender has perhaps drawn the greatest critical interest of physiotherapists. From Anne Parry’s early paper, Ginger Rogers Did Everything Fred Astaire Did Backwards and in High Heels ^[1], and Ruby Heap’s research into the gendering of women’s physiotherapy training in Canada ^[2], we have seen over the last 25 years a smattering of studies looking at gendered power ^[3][4][5], the gendered division of labour ^{[6][7][8][9][10]}, studies of the gendered history of the profession ^[11][12][13], gendered role identities ^[14][15][16], the gendering of bodies ^[17][18][19], clinical implications of gender theory ^[20], gendered aspects of touch ^[21][22], the role of gender in professional prestige ^[23], and gendered aspects of practice learning ^{[24][25][26][27][28]}. But this represents only a tiny percentage of the research done in physiotherapy, and pales into insignificance when compared with the attention given to gender in medicine and nursing ^{[29][30][31][32][33][34][35]}.

The radical, or second wave, feminism that emerged after the 1950s took a different view of gender politics to the liberal first wave of Mary Wolstencraft and the suffragette movement. Where first wave liberal feminism fought to overthrow laws that ‘denied women the right to work, to own property, to vote, to divorce, to receive higher education, and professional training and to make their own decisions about sexual and reproductive practices’ ^[36], second wave feminists fought the ways society had been structured to oppress and disadvantage women, to make them victims of sexist exploitation, and to regulate the distribution of global resources so that women consistently fall below the levels achieved by men ^[37][38]. It asked what kinds of social structures consistently resulted in women doing ‘two thirds of the world’s work for 1/10 of the world’s income’, owning ‘less than 1 per cent of the world’s property’, as well as making up ‘two thirds of the world’s illiterate’, and being ‘only 16% of the world’s parliamentarians’ ^[39].

As Pip Jones and Liz Bradbury argued, the women’s liberation movement challenged ‘the formal and informal structures, practices and normative values of male authority that defined and regulated both the public and private spheres’ (ibid). Jones and Bradbury asked rhetorically; should a woman’s ability to bear children dictate her entire life, rule her ambitions, determine that she should always be paid less, or confine her to socially mandated roles (like stay-at-home mom, or virtuous nurse) (ibid)?

Feminists argued that the organisation of social systems in capitalist societies did not merely perpetuate the subordination of women, but actually depended upon it ^[40]. Women provide vastly more unpaid domestic service and low-paid professional labour than men, thereby bringing down the economic cost of work, and, like the Ragged Trousered Philanthropists in Chapter 3, extracting surplus profits for the men that control the means of production ^{[41][42][43][44]}.

Anne Oakley’s detailed study of the distinction between housework and professional labour is a particularly powerful example of this ^[45]. Oakley argued that housework reflected women’s unpaid and uncelebrated labour that emerged following the Industrial Revolution, when domestic and gender roles became attenuated by the need to perform some work at the lowest possible cost to capital. As Oakley reminds us with the well-known aphorism; “if you watch Cinderella backwards it’s about a woman who learns her place” (ibid). Similarly, Elizabeth Grosz argued that medical knowledge saw women’s bodies as inferior to men; as troublesome, and in need of greater care and attention ^[46]. Women were frequently portrayed as weaker, passive, irrational and illogical, manipulative, subjective, intuitive, emotional, and unreliable ^[47].

Feminist scholars argued that masculine approaches to healthcare embodied ‘phallocentric’ traits of domination, control, power, and objectivity, that resulted in overly invasive interventions designed to reflect well on men’s heroism, and emphasise women’s caring support for this work ^[48][49]. Patriarchal attitudes also flow through every facet of healthcare, from the extent that male doctors have traditionally specialised in ‘heroic’ disciplines like orthopaedics and intensive care ^[50][51], to the role that nurses, physiotherapists, and other female dominated health professionals play as ‘vassals’ of medicine ^[52]. In healthcare, gender asymmetries are not only perpetuated through the work of nurses and other female-dominated professions ^{[53][54][55][56]},including the allied health professions too ^{[57][58][59][60]}, where the perpetuation of lower pay and low status for female dominated professions allows the accumulation of prestige and economic capital by the largely male dominated elite medical professions ^[61][62][63].

Often the skills associated with ‘women’s work’ are less valued; ‘caring tasks are something that women simply ‘do’ rather than skills that both women and men might need to acquire’ ^[64]. Because caring, relationship building, empathy, and other ‘soft’ skills (note the gendered language here), are assumed to be women’s ’natural tendencies’, they are assumed to be hard to instrumentalise and learn, and so rarely feature in medical training in the same way as other technical skills. This gendered division of labour mimics capitalist patriarchal society, propagating the belief that caring attitudes are less accessible to men, or are, at least, harder to learn for those not naturally predisposed towards caring ^[65][66][67]. They are also assumed to be natural dispositions that women should offer without recognition or reward. At the same time, by claiming objectivity, detachment, and value-neutrality as masculine traits that can be accessed only through rigorous scientific study, elite male practitioners have argued that these traits are justifications for high social status and financial reward ^[68][69][70].

Western medicine, argued Malika Sharma, has for too long operated ’under the notion that it is value neutral, an occurrence that has been referred to as the “culture of no culture”’ ^[71]. ‘By failing to interrogate its own culture’, Sharma suggests, ‘this so-called view from nowhere can reinforce societal, patriarchal, or cultural norms in medical education’ (ibid). Western medicine exemplifies patriarchal attitudes to health, being based on ‘a particular kind of logic that embraces heroism, rationalism, certainty, the intellect, distance, objectification, and explanation before appreciation’ ^[72].

And yet, if medicine is as value-neutral, objective, disinterested, and based on factual knowledge as it claims, how can it manage to perpetuate the subordination of women even while claiming not to ^[73]? This proved, as Evelyn Keller suggested, that ‘in characterising scientific and objective thought as masculine, the very activity by which the knower can acquire knowledge is gendered’ ^[74].

Celia Davies took this argument further, to show that even the concept of professional autonomy was ‘a masculine one, rooted in a vision of rationality and technological mastery as the appropriate ways of organising the most efficient form of authority in complex society’ ^[75]. Davies suggested that the gendered nature of autonomy explained why some female-dominated professions struggled to follow the same path to professionalisation as medicine. Fundamentally, women have what Witz called ‘differential access’ to the kinds of resources that would allow for equality of opportunity ^[76], and so they repeatedly encounter structural barriers (social attitudes, pay differentials, lack of mentors, etc.), that prevent them from advancing professionally ^[77].