The meanings given to gender in studies on multimodal rehabilitation for patients with chronic musculoskeletal pain - a literature review.

PURPOSE: The purpose of this study is to assess and describe the meanings given to "gender" in scientific publications that evaluate multidisciplinary, interdisciplinary or multimodal rehabilitation for patients with chronic musculoskeletal pain. METHOD: A systematic literature search for papers evaluating multimodal rehabilitation was conducted. The PubMed and EBSCO databases were searched from 1995 to 2015. Two or three researchers independently read each paper, performed a quality assessment and coded meanings of gender using qualitative content analysis. RESULTS: Twenty-seven papers were included in the review. Gender was used very differently in the MMR studies investigated but primarily it referred to factual differences between men and women. Only one paper provided a definition of the concept of gender and how it had been used in that study. In the content analysis, the meaning of gender formed three categories: "Gender as a factual difference", "The man is the ideal" and "Gender as a result of social role expectations". CONCLUSIONS: The meaning of the concept of gender in multimodal rehabilitation is undefined and needs to be developed further. The way the concept is used should be defined in the design and evaluation of multimodal rehabilitation in future studies. Implications for rehabilitation Healthcare professionals should reflect on gender relations in encounters with patients, selection of patients into rehabilitation programs and design of programs. In rehabilitation for chronic pain the patients' social circumstances and cultural context should be given the same consideration as biological sex and pain symptoms.

Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections.

OBJECTIVE: To explore how gender is addressed in medical articles on the prevention of sexually transmissible infections (STI) among adolescents. METHODS: Sixtyone articles were retrieved from a PubMed search and scrutinized by qualitative content analysis. RESULTS: Most articles were affiliated with North American research institutions, but there were also reports from Europe, Africa, South America, and Asia. Gender turned up in the following four recurrent discourses: Gendered Receptiveness for Information, Stereotyped Heterosexual Expectations, Power Imbalance in Sexual Relations, and Gendered Prevention Approaches. Young women were described as knowledgeable, communicative, and responsible, but at risk because of feminine ideals and a lack of negotiating power. Men were described as less informed, more reluctant to discuss, and more risk taking due to masculine ideals and power dominance. Prevention approaches concerned how to postpone sex and/or tailor gender-sensitive programs for specific groups of young women and men. CONCLUSION: Researchers' own gender expectations might have a substantial impact on how sex and sexual health is considered in prevention research. To avoid reconstruction of current inequalities and stereotypes regarding sexual practices of young women and men, the impact of gender, the power structures in intimate relations, and the cultural context should be considered. Medical research on STI prevention could benefit from including a wider array of gender perspectives.

"Grin(d) and bear it": narratives from Sami women with and without temporomandibular disorders. A qualitative study.

AIMS: To explore thoughts, experiences, and beliefs regarding temporomandibular disorders (TMD) among Sami women with and without TMD in order to gain insights into their health care experiences and to generate a hypothesis regarding factors associated with long-standing TMD. METHODS: Qualitative thematic interviews were conducted with a strategic sample of 17 Sami women, of whom 10 had a TMD diagnosis according to the Research Diagnostic Criteria for TMD and 7 age-matched women who had no signs or symptoms of TMD. Their ages were between 23 and 58 years. The thematic interviews were audiotaped, transcribed verbatim, and analyzed based on Grounded Theory, a qualitative methodology aiming to generate hypotheses grounded in the gathered data. RESULTS: The core category that evolved was "Grin(d) and bear it," which summarizes the Sami participants' various ways and stages of processing and handling the interacting categories (triggers, strains, distrust, and reconciliation with pain and/or difficulties in life). They described divergent as well as similar understandings of triggering factors. Maintaining factors were described as mental-physical strain and stress, and also a jaw-clenching behavior. Women without TMD contributed with factors that helped them to handle strains, reconcile, and stay healthy. They relied on strong social support. CONCLUSION: Based on the analysis, the following hypothesis was generated: Women with TMD, associated headaches, and neck-shoulder pain may benefit from efforts aimed at empowering them to use their own abilities to reduce stress behavior, strain, and disuse of the jaw. Rehabilitation strategies in groups might increase their sense of coherence and increase social support, which seems to be more limited than in women with no symptoms of TMD.

Women's experiences of internet-based or postal treatment for stress urinary incontinence.

Stress urinary incontinence is common and sometimes embarrassing. New, simple, and easily accessible treatments are needed. We telephone interviewed 21 women who participated in a randomized controlled study comparing two treatment programs based on instructions for pelvic floor muscle training. One program was Internet-based and included email support by a urotherapist; the other was sent by post. There was no face-to-face contact in either program. Our main aim was to explore the women's experiences of the Internet-based treatment. Grounded theory analysis revealed three categories: hidden but present, at a distance but close, and by myself but not alone. These were incorporated in a core category: acknowledged but not exposed. The leakage was often a well-hidden secret, but the study treatments lowered the barrier for seeking care. In the Internet group, a supportive patient-provider relationship developed despite the lack of face-to-face contact. Internet-based treatment programs can increase access to care and empower women.

Few gender differences in specialty preferences and motivational factors: a cross-sectional Swedish study on last-year medical students.

BACKGROUND: Today, women constitute about half of medical students in several Western societies, yet women physicians are still underrepresented in surgical specialties and clustered in other branches of medicine. Gender segregation in specialty preference has been found already in medical school. It is important to study the career preferences of our future physicians, as they will influence the maintenance of an adequate supply of physicians in all specialties and the future provision of health care. American and British studies dominate the area of gender and medical careers whereas Swedish studies on medical students' reasons for specialty preference are scarce. The aim of this study is to investigate and compare Swedish male and female medical students' specialty preferences and the motives behind them. METHODS: Between 2006 and 2009, all last-year medical students at Umea University, Sweden (N = 421), were invited to answer a questionnaire about their future career and family plans. They were asked about their specialty preference and how they rated the impact that the motivational factors had for their choice. The response rate was 89% (N = 372); 58% were women (N = 215) and 42% were men (N = 157). Logistic regression was used to evaluate the independent impact of each motivational factor for specialty preference. RESULTS: On the whole, male and female last-year students opted for similar specialties. Men and women had an almost identical ranking order of the motivational factors. When analyzed separately, male and female students showed both similarities and differences in the motivational factors that were associated with their specialty preference. A majority of the women and a good third of the men intended to work part-time. The motivational factor combining work with family correlated with number of working hours for women, but not for men. CONCLUSIONS: The gender similarities in the medical students' specialty preferences are striking and contrast with research from other Western countries where male and female students show more differences in career aspirations. These similarities should be seized by the health care system in order to counteract the horizontal gender segregation in the physician workforce of today.

Comparing gender awareness in Dutch and Swedish first-year medical students--results from a questionaire.

BACKGROUND: To ascertain good and appropriate healthcare for both women and men implementation of gender perspectives in medical education is needed. For a successful implementation, knowledge about students' attitudes and beliefs about men, women, and gender is crucial. The aim of this study was to compare attitudes to gender and gender stereotyping among Dutch and Swedish male and female medical students. METHODS: In this cross-sectional study, we measured the attitudes and assumptions about gender among 1096 first year medical students (616 Dutch and 480 Swedish) with the validated Nijmegen Gender Awareness in Medicine Scale (N-GAMS). The response rate was 94% in the Netherlands and 93% in Sweden. Univariate analysis of variance (ANOVA) was used to compare the scores between Dutch and Swedish male and female students. Linear regressions were used to analyze the importance of the background variables. RESULTS: There were significant differences in attitudes to gender between Dutch and Swedish students. The Swedish students expressed less stereotypical thinking about patients and doctors and the Dutch were more sensitive to gender differences. The students' sex mattered for gender stereotyping, with male students in both countries agreeing more with stereotypical statements. Students' age, father's birth country and mother's education level had some impact on the outcome. CONCLUSIONS: There are differences between cultures as well as between men and women in gender awareness that need to be considered when implementing gender in medical education.This study suggests that to arouse the students' interest in gender issues and make them aware of the significance of gender in medical work, the examples used in discussions need to be relevant and challenging in the context of the specific country. Due to different levels of knowledge and different attitudes within the student population it is important to create a climate for dialogue where students feel permitted to disclose their ideas and attitudes in order to become aware of what these are as well as their possible consequences on interaction and decision-making in medical work.

Medical students' experiences of shame in professional enculturation.

CONTEXT: Despite the intentions of caregivers not to harm, medical encounters may involve intimidation and induce emotions of shame. Reflection is a critical part of professional learning and training. However, the role of shame in medical education has scarcely been studied. The aim of this study was to explore medical students' reflections on shame-related experiences in clinical situations and to examine how they tackled these experiences. METHODS: A 24-credit course in Professional Development is held at the Medical School of Umeå University, Sweden. A 1-day seminar on the theme of shame, which involves individual reflections and group discussions, is held in term 9. Medical students were invited to individually consider and write down their memories of situations in which they had experienced shame in clinical encounters. Of a total of 133 students, 75 were willing to share their written reflections anonymously. Their essays were transcribed to computer text and analysed by means of qualitative content analysis. RESULTS: Three themes emerged. These included: Difficulties in disclosing shame; Shame-inducing circumstances, and Avoiding or addressing shame. Initially, students experienced problems in recalling shameful incidents, but successively described various situations which related to being taken by surprise, being exposed, and being associated with staff imprudence. Students disclosed shame avoidance behaviours, but also gave examples of how addressing shame provided them with new insights and restored their dignity. CONCLUSIONS: Students' reflections on shameful experiences elucidated the importance of attitudes, manners, standards and hierarchies in clinical situations. These are important issues to highlight in the professional enculturation of medical students; our emphasising of them may encourage medical teachers elsewhere to organise similar activities. Opportunities for mentoring medical students in tackling shame and adverse feelings, and in resolving conflict, are needed in medical curricula.

'Important but of low status': male education leaders' views on gender in medicine.

OBJECTIVES: The implementation of and communication about matters associated with gender in medical education have been predominantly perceived as women's issues. This study aimed to explore attitudes towards and experiences of gender-related issues among key male members of faculties of medicine. METHODS: We conducted semi-structured interviews with 20 male education leaders from the six medical schools in Sweden. The interviews were analysed qualitatively using a modified grounded theory approach. RESULTS: The core category--'important… but of low status'--reflects ambivalent attitudes towards gender-related issues in medicine among male education leaders. All informants were able to articulate why gender matters. As doctors, they saw gender as a determinant of health and, as bystanders, they had witnessed inequalities and the wasting of women's competence. However, they had doubts about gender-related issues and found them to be overemphasised. Gender education was seen as a threat to medical school curricula as a consequence of the time and space it requires. Gender-related issues were considered to be unscientifically presented, to mostly concern women's issues and to tend to involve 'male bashing' (i.e. gender issues were often labelled as ideological and political). Interviewees asked for facts and knowledge, but questioned specific lessons and gender theory. Experiences of structural constraints, such as prejudice, hierarchies and homosociality, were presented, making gender education difficult and downgrading it. CONCLUSIONS: The results indicate that male faculty leaders embrace the importance of gender-related issues, but do not necessarily recognise or defend their impact on an area of significant knowledge and competence in medicine. To change this and to engage more men in gender education, faculty measures are needed to counteract prejudice and to upgrade the time allocation, merits and status of gender implementation work. Based on our findings, we present and discuss possible ways to interest more men and to improve gender education in medicine.

"My greatest dream is to be normal": the impact of gender on the depression narratives of young Swedish men and women.

Depression is common among young people. Gender differences in diagnosing depression appear during adolescence. The study aim was to explore the impact of gender on depression in young Swedish men and women. Grounded theory was used to analyze interviews with 23 young people aged 17 to 25 years who had been diagnosed with depression. Their narratives were marked by a striving to be normal and disclosed strong gender stereotypes, constructed in interaction with parents, friends, and the media. Gender norms were upheld by feelings of shame, and restricted the acting space of our informants. However, we also found transgressions of these gender norms. Primary health care workers could encourage young men to open up emotionally and communicate their personal distress, and young women to be daring and assertive of their own strengths, so that both genders might gain access to the positive coping strategies practiced respectively by each.

"The Western gaze"--an analysis of medical research publications concerning the expressions of depression, focusing on ethnicity and gender.

Our aim of this study was to explore how authors of medical articles wrote about different symptoms and expressions of depression in men and women from various ethnic groups as well as to analyze the meaning of gender and ethnicity for expressions of depression. A database search was carried out using PubMed. Thirty articles were identified and analyzed using qualitative content analysis. Approaches differ with regard to how depression is described and interpreted in different cultures in relation to illness complaints, illness meaning, and diagnosis of depression. Articles often present issues based on a Western point of view. This may lead to "cultural or gender gaps," which we refer to as "the Western gaze," which may in turn influence the diagnosis of depression.

Struck by lightning or slowly suffocating - gendered trajectories into depression.

BACKGROUND: In family practice depression is a common mental health problem and one with marked gender differences; women are diagnosed as depressed twice as often as men. A more comprehensive explanatory model of depression that can give an understanding of, and tools for changing, this gender difference is called for. This study explores how primary care patients experience, understand and explain their depression. METHODS: Twenty men and women of varying ages and socioeconomic backgrounds diagnosed with depression according to ICD-10 were interviewed in-depth. Data were assessed and analyzed using Grounded Theory. RESULTS: The core category that emerged from analysis was "Gendered trajectories into depression". Thereto, four categories were identified - "Struck by lightning", "Nagging darkness", "Blackout" and "Slowly suffocating" - and presented as symbolic illness narratives that showed gendered patterns. Most of the men in our study considered that their bodies were suddenly "struck" by external circumstances beyond their control. The stories of study women were more diverse, reflecting all four illness narratives. However, the dominant pattern was that women thought that their depression emanated from internal factors, from their own personality or ways of handling life. The women were more preoccupied with shame and guilt, and conveyed a greater sense of personal responsibility and concern with relationships. CONCLUSION: Recognizing gendered narratives of illness in clinical consultation may have a salutary potential, making more visible depression among men while relieving self-blame among women, and thereby encouraging the development of healthier practices of how to be a man or a woman.

A theoretical model for analysing gender bias in medicine.

During the last decades research has reported unmotivated differences in the treatment of women and men in various areas of clinical and academic medicine. There is an ongoing discussion on how to avoid such gender bias. We developed a three-step-theoretical model to understand how gender bias in medicine can occur and be understood. In this paper we present the model and discuss its usefulness in the efforts to avoid gender bias. In the model gender bias is analysed in relation to assumptions concerning difference/sameness and equity/inequity between women and men. Our model illustrates that gender bias in medicine can arise from assuming sameness and/or equity between women and men when there are genuine differences to consider in biology and disease, as well as in life conditions and experiences. However, gender bias can also arise from assuming differences when there are none, when and if dichotomous stereotypes about women and men are understood as valid. This conceptual thinking can be useful for discussing and avoiding gender bias in clinical work, medical education, career opportunities and documents such as research programs and health care policies. Too meet the various forms of gender bias, different facts and measures are needed. Knowledge about biological differences between women and men will not reduce bias caused by gendered stereotypes or by unawareness of health problems and discrimination associated with gender inequity. Such bias reflects unawareness of gendered attitudes and will not change by facts only. We suggest consciousness-rising activities and continuous reflections on gender attitudes among students, teachers, researchers and decision-makers.

Gaps between patients, media, and academic medicine in discourses on gender and depression: a metasynthesis.

For reasons that are not yet fully understood, depression affects women twice as often as men. In this article we describe an investigation of how depression is understood in relation to men and women by the patients themselves, the media, and the medical research establishment. We do this by undertaking a metasynthesis of data from three different sources: interviews with depressed patients, media portrayals of depressed individuals in Sweden, and international medical articles about depression. The findings reveal that there are differences in (a) the recognition of depression, (b) the understanding of the reasons for depression, and (c) the contextualization of depression. Although women and men describe different symptoms and reasons for falling ill, these gendered expressions are not acknowledged in articles coming from Western medical settings. We discuss the implications of these findings and conclude that an integrated model for understanding biological, gender, and cultural aspects of depression has yet to be developed.

'Aiming for the stars'--GPs' dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews.

BACKGROUND: Studies have revealed low adherence to guidelines for treatment of diabetes and cardiovascular risk factors. OBJECTIVE: To explore GPs' experiences regarding treatment practice in type 2 diabetes with specific focus on the prevention of cardiovascular disease. METHODS: Fourteen experienced GPs from nine health care centres with group practices were interviewed in focus groups. The interviews were digitally recorded, transcribed verbatim and analysed by qualitative content analysis. RESULTS: The overall theme was 'dilemmas' in GPs' treatment practice for type 2 diabetes patients. Five main dilemma categories were identified. First, the GPs were hesitant about labelling someone who feels healthy as ill. Second, regarding communicating a diabetes diagnosis and its consequences; should the patient be frightened or comforted? Third, the GPs experienced uncertainty in their role; were they to take responsibility for the care or not? Fourth, the GPs expressed a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties in integrating science into reality. CONCLUSIONS: The five dilemmas in the GPs' approach to diabetes patients and the treatment of their cardiovascular risk were related to the GPs' professional role and communication with the patient. To consider these dilemmas in educational efforts is probably essential to achieve improved diabetes care and guideline adherence.

Longing and fearing for dialogue with children: depressed parents' way into Beardslee's preventive family intervention.

There is a growing interest in prevention of mental disorders in children of mentally ill parents. Beardslee's preventive family intervention is a method recently introduced into Sweden. When asking parents to participate in this intervention, it has become evident how sensitive the issue of parenthood is to our patients. The study aims at exploring what depressed parents considered as obstacles and facilitating factors for accepting Beardslee's family intervention. Ten parents from two psychiatric clinics and one primary healthcare centre in northern Sweden were interviewed by semi-structured technique. Nine of these parents had accepted and participated in Beardslee's family intervention; one parent had been offered but refused participation. Data were analysed according to grounded theory. The main reason for taking part was the lack of dialogue these parents perceived with their children. There were difficulties in talking about and finding words to explain the depression. The parents were worried about their children, wishing to know how the children were actually feeling, and wanting the professionals to take a look at them. To open up was both frightening and tempting. It implied the consideration of many aspects: the right timing, shame and guilt, the partner's interest, the children's willingness and the involvement of professionals. The findings show the delicacy of the issue of children's well-being when a parent is depressed and they highlight some important topics to discuss with the parents when preventive interventions are offered.

Attitudes toward and experiences of gender issues among physician teachers: a survey study conducted at a university teaching hospital in Sweden.

BACKGROUND: Gender issues are important to address during medical education, however research about the implementation of gender in medical curricula reports that there are obstacles. The aim of this study was to explore physician teachers' attitudes to gender issues. METHODS: As part of a questionnaire, physician teachers at Umeå University in Sweden were given open-ended questions about explanations for and asked to write examples why they found gender important or not. The 1 469 comments from the 243 respondents (78 women, 165 men) were analyzed by way of content analysis. The proportion of comments made by men and women in each category was compared. RESULTS: We found three themes in our analysis: Understandings of gender, problems connected with gender and approaches to gender. Gender was associated with differences between women and men regarding behaviour and disease, as well as with inequality of life conditions. Problems connected with gender included: delicate situations involving investigations of intimate body parts or sexual attraction, different expectations on male and female physicians and students, and difficulty fully understanding the experience of people of the opposite sex. The three approaches to gender that appeared in the comments were: 1) avoidance, implying that the importance of gender in professional relationships was recognized but minimized by comparing gender with aspects, such as personality and neutrality; 2) simplification, implying that gender related problems were easy to address, or already solved; and 3) awareness, implying that the respondent was interested in gender issues or had some insights in research about gender. Only a few individuals described gender as an area of competence and knowledge. There were comments from men and women in all categories, but there were differences in the relative weight for some categories. For example, recognizing gender inequities was more pronounced in the comments from women and avoidance more common in comments from men. CONCLUSION: The surveyed physician teachers gave many examples of gender-related problems in medical work and education, but comments describing gender as an area of competence and knowledge were few. Approaches to gender characterized by avoidance and simplification suggest that faculty development programs on gender need to address and reflect on attitudes as well as knowledge.

The Law of Communicable Diseases Act and disclosure to sexual partners among HIV-positive youth.

In Sweden, human immunodeficiency virus (HIV) is included among the venereal diseases covered by the Law of Communicable Diseases Act. HIV-positive (HIV(+)) people are required to inform their sexual partners about their infection and adopt safe sex behaviours. However, it is unclear how the law is perceived. This study explores how HIV(+) youth in Sweden perceive the law, handle their sexuality and disclose their HIV diagnosis to sexual partners. Ten HIV(+) women and men between 17 and 24 years of age were recruited from three different HIV infection clinics. These participants were interviewed in depth. The interviews were tape-recorded, transcribed verbatim and analysed according to a grounded theory approach. The core category-cultured to take responsibility-illuminates the informants' double-edged experiences regarding the law and how they handle disclosure to sexual partners. The legislation implies both support and burden for these HIV(+) youth; they feel that they have a great deal of responsibility, sometimes more than they can handle. 'Switch off lust', 'balancing lust, fear and obedience' and 'switch off the disease' are strategies that describe how the informants manage sexuality and disclosure. Young HIV(+) people have a difficult time informing partners of their HIV diagnosis and discussing safe sex strategies. These are challenges that health care providers need to take seriously. HIV(+) youth need better communication strategies to negotiate safer sex. Staff with extended education on sexuality should be a part of HIV health care.

From calling to a scheduled vocation: Swedish male and female students' reflections on being a doctor.

BACKGROUND: All over the world an increasing number of women are entering medical schools. Soon women will constitute half of the physician workforce in Scandinavia. However, specialty segregation persists. Reports have shown different motives among male and female doctors to be, but the impact of gender, i.e. how ongoing social constructions of femininity and masculinity influence the development of professionalism, is not fully described. AIM: The purpose of this study was to explore views and visions among second-year students at a Swedish Medical School, and to identify challenges for education and workforce planning. METHODS: After receiving research ethics board approval, all students participating in the course 'Professional development', including a task to write a free-text essay on the theme 'to be a doctor', were invited to share their essays for analysis. Of 138 (40% men) students in 2002, 104 (39% men) accepted. The texts were analysed according to grounded theory. RESULTS: Students held 'doctorship' to be an outstanding profession of commitment, authority and duty. Fears were exposed, especially among women, regarding how to fit demands of self-sacrifices and balancing a private life. Belonging to a new generation, they conceived gender equity as self-evident. Actual working conditions were met with disapproval, as did an all-embracing calling. A scheduled vocation was hoped for. They relied on the mass of women to implement change. Women's 'other' values, alluding to family orientation, were expected to alter working conditions and also give men more leisure time. Despite equity conviction, segregating gender patterns in students' representations, interactions with tutors and future prospects were disclosed. CONCLUSIONS: Students' arguments raise challenges for medical educators and planners regarding professional values, medical socialization and specialty recruitment. The new generation requires a renewed Hippocratic Oath, gender-aware role models and practice sites. Swedish students' arguments are compared with current international literature.