The birth of the Roman Republic, which would soon transform into a vast empire with a monumental legacy, has brutal origins all beginning with a rape victim. It’s no secret the Romans were excellent storytellers; the proof is longevity. Roman myths, passed down for generations, outlived their society and continue to echo off the tongues of modern storytellers.
The story of Lucretia is a mythological and historical tale that has survived since the early origins of Roman history, over two thousand years since its believed origins in 509 BCE. It was narrated and criticized in several different versions of works by prolific Roman writers such as Livy, Ovid, and Dionysius. Gaining popularity immediately after her death, Lucretia became a legendary symbol of beauty, virtue, and chastity. Subsequently, Roman society encouraged women, and especially young girls, to view her as a matron for model behavior.
As the victim of the story, the glorification of Lucretia’s story after her death reveals deeper insight into the sexist roles women were expected to conform to in ancient Rome.
In Book 1 of Ab Urbe Condita, “From the Founding of the City,” Titus Livius, or Livy, a Roman historian whose works are largely viewed as reliable historical sources, recounts Lucretia’s story. Livy narrates the events leading up to the climax of her rape, as well as the aftermath and her impact on the founding of the republic. The story begins with Lucius Tarquinius Collatinus, Lucretia’s husband, and his companions drinking at the house of Sextus Tarquinius, son of the king Tarquinius Superbus, one night. The men drunkenly argue on the subject of wives, each man praising his own, and Collatinus decides that the mere sight of his wife at such late hours would put an end to the debate altogether. They mount their horses and head to Collatia, a Roman town governed by Collatinus, and into the quarters where Lucretia resides. Upon entering, Lucretia is seen weaving wool by herself by the lamplight with only the company of slave girls, unlike the other wives who had spent their night mingling and drinking with each other. This alone is meant to portray her legacy as a woman of the utmost chastity and virtue. Lucretia wins “the prize of this contest in womanly virtues”1 for her devotion to her husband and home. Sextus, intrigued by her beauty, is “seized by wicked desire”2 to conquer her modesty.
A few days later, he returns to Collatia again, this time without Collatinus. His motives unsuspected, Sextus is welcomed to dinner in their home and is provided guest chambers for his seemingly innocuous visit. Late into the night, he enters Lucretia’s room while she is asleep. A knife in one hand, Sextus holds her down while clasping onto her breast with the other, and threatens her to comply with his wishes, otherwise he would lay the dead naked body of a male slave next to her corpse and frame her for adulterous acts. Sextus then rapes her.
Afterwards, Lucretia, frightened and upset, sends a message to her father and Collatinus to return home with trusted companions so that she can recount all of this. All of the men are enraged by Sextus’ actions. They reassure her that “it is the mind that sins, not the body.”3 This part of the story is particularly interesting as it challenges the norms in Roman society by unexpectedly diverting blame onto the perpetrator rather than the victim who was raped. In the end though, Lucretia deeply fears that her virtue has been “ruined” by Sextus and does not wish to be an “impure” example to Roman wives. She admits that although her heart does not hold any guilt, and that she absolves herself of blame from the rape, she still cannot free herself from punishment. Lucretia reveals a knife she hid under her dress and thrusts it into her chest out of shame as Collatinus, her father, and their companion named Junius Brutus bear witness. Just before committing suicide, she urged the men to decide Sextus’ fate. It is evident she herself prefers to die before being seen as a role model to unchaste women.
Lucretia’s rape was also the impetus of political revolution in Rome. Collatinus and Brutus led the overthrow of Sextus’s father and exiled the Tarquins from Rome. A new form of government was established in 509 BCE, with Collatinus and Brutus serving as the first pair of consuls of the Roman Republic.
Lucretia’s suicide was socially viewed as honorable by Romans, and she was subsequently immortalized as a heroine. Given that her story serves as thematic for proper behavior for women in Rome, it further reveals incredibly sexist ideals present in Roman society. Lucretia’s position as the embodiment of pudicitia, a term used to describe virtuous women, would only grow after she died. Sexual ethics were deeply conceptualized in ancient Rome; there were several intricate terms to describe one’s social as well as physical position regarding male and female sexuality. Pudicitia was a distinctly feminine descriptor of one’s character, predominantly in relation to morality and sexual fidelity.
It is important to recognize that the male equivalent of this quality did exist in the form of virtus, meaning virtue, although not nearly to the same extent women were judged. Pudicitia was not praised as a positive ideal in men, rather, it was viewed as a neutral trait for males, and could sometimes be simply reduced to whether they acted in the dominant role in sexual relations with other men.4 Much of the explanation as to why a woman’s chastity held so much value in ancient Rome was due to the fact that it ensured they were kept “pure” for men until marriage. Lucretia’s virtue and sexual modesty was promoted as a feminine ideal through “deeply conservative and patriarchal impulse.”5 It is important to address the emphasis on virginity as men were certainly not scrutinized to the same standards. Roman girls were purposefully married young, the legal age twelve, to “ensure an undefiled body and mind.”6 This view alone amplifies the misogynistic logic used by the ancient Romans to control female sexuality and restrict freewill.
As expected, Roman societal structures continued to subjugate women throughout the longevity of the republic and empire. The specific reasons for this perceived inferiority of women thrived on their generalization as “fragile and fickle, therefore in need of protection.”7 A plausible explanation for these rigid social structures is the historical dichotomy of men as “protectors” and women as “childbearers.” Additionally, it was a widespread belief that women were “emotional, irrational, and intellectually less capable than men”8 to the point where objections to such beliefs were controversial. In a speech written by Livy, capturing the thoughts of Cato says: “Our ancestors decided that women should not handle anything…they should always be in power of fathers, brothers, husbands. If once they get equality, they’ll be on top.”9 In contrast, Musonius, a Stoic philosopher, argued that women possessed reason and logic, were inclined towards good virtue just like men, and that “men should have as high a standard of sexual virtue as women.”10
Marriage was beyond a sufficient reason society deemed it unworthy for girls to continue their education, instead prioritizing domestic tasks and tending to the wishes of their husbands. It is also dire to address the fact that the majority of the available information about the daily lives of Roman women is provided through the lens of men, often incidental in orations or letters or poems.11 It is clear the ancient Romans did not prioritize women’s education nor urge them to contribute to literature or philosophy. The already lacking information about the daily lives of women is focused on upper class women, with scarce information about common women. In the study of classics, a field that has traditionally been dominated by men, studying the lives of ancient women was an academic priority until recent feminist perspectives concerning historical analysis emerged.
It is known that Roman women were established as subservient to men in all aspects of life; their names were technically not even their own. A Roman woman’s name was the feminine form of her father’s gentilicium during the early republic, which was passed down to all of the sisters, and also shared with aunts and cousins on her paternal side.12 Marriage was largely an social and economic proposition for both parties since the Romans rarely married for happiness and romantic love; the latter was usually reserved for extramarital affairs.
Additionally, women had limited citizenship status, meaning they could not vote or run for public office, and in many cases their properties were under control of their father and eventually husband. Specific terms evolved for circumstances of marriage: cum manu, “with the hand,” and sine manu, “without the hand.” A woman who was married cum manu was no longer under her father’s authority, but under the legal control of her husband.13 This meant that she was under potestas, “power,” of her husband rather than her father. If she was married cum sine, which was common in the late republic, she remained under her father’s control. She needed his approval to make important financial transactions, and “might have her marriage ended by him even against her wish.”14 In a divorce, which women were allowed to bring forth under legally valid conditions, children were no longer left to her, but rather to her husband’s family.
A woman’s influence was not acknowledged in the public sphere; they were restricted to domestic matters concerned with running the home. Such partially demonstrates why Lucretia was glorified above the other wives from the moment Collatinus and his companions found her tending to her weaving, historically one of the most domestic chores, instead of away socializing with other women. A “virtuous” Roman wife influenced by the precedent of Lucretia behaved modestly, felt great devotion to her husband and tended to his needs, and most importantly valued her chastity, and in this legendary case, above her own life.
The widespread idealization of Lucretia in ancient Rome provides insight into the way Romans viewed the social structures of gender, family life, law, and marriage. Often portrayed as a docile victim, it is clear Lucretia embodies the submissive traits women were expected to display in order to fit the status quo. Although in modern times her story is often regarded as a mere puzzle piece in the larger image of ancient Rome, it continues to raise questions regarding the position of women in a society where they were severely oppressed.
People have always been interested in learning about influential people’s lives — through both gossip and the media. Whether we’re learning about Jennifer Aniston’s new fling, Kim Kardashian’s pregnancy, or Harry Styles’s secret vacation, we often interest ourselves with other people’s lifestyles, namely celebrities, because we feel as if we personally know them through our powerful admiration and devotion. We see celebrities as heroes; people we aspire to be like. But why are we so drawn to the lives of villains as well?
Recently, women have developed a strong obsession with true crime, a literary and film genre in which the author examines an actual crime and exposes the actions committed by real people; specifically, there has been a sudden fascination with serial killer crimes. This infatuation with evil reveals our desire to uncover the secrets and truth behind those who commit the horrific acts we abhor. Perhaps it fascinates us that these famous perpetrators hold such obvious disregard for morality and societal values; we feel obligated to witness the dramatic scenes unfold as a means of “preparation” for any real-life danger.
From Ted Bundy to Charles Manson, women often find themselves deluded into romanticizing famous serial killers. We find it hard to accept that attractive people are just as capable of committing grotesque crimes as ordinary people. Recently, the Joker movie played by Joaquin Phoenix, though fictional, has captured the attention of young girls infatuated with his depressing life story and motivation to commit heinous crimes that are similar to real killers. Though women are more likely to be victims of a major crime, for some reason they feel increasingly attracted to the vile and twisted side of history, intrigued to learn about the ways in which they can face danger.
Psychologists conducted a 2010 study at the University of Illinois to investigate the relationship between gender and the true-crime audience. Psychologist R. Chris Fraley and their team discovered that women wrote 70% of the true-crime book reviews on Amazon, while men felt a greater connection to war books, writing 82% of reviews (Yates). The researchers hypothesized why women may feel an increased inclination to read more true crime and suggested that such stories can provide useful information that may help readers avoid or escape potential attacks such as murder or rape. To investigate this claim, the psychologists reviewed the summaries of the books most often reviewed by women. Further study revealed that women were more likely to read a true crime book if the victim used a clever ‘psychological trick’ to deceive and escape from their perpetrator. Unsurprisingly, women also felt attracted to true crime books with female victims. Thus, evidence strongly suggests that women tend to read more true crime books with clever female survivors because they provide a ‘guide’ of instructions as to how to avoid deadly encounters in real life. If women consume as much violence as they can in art, maybe they can escape the true violence that unfortunately lingers in our reality.
Recently, the producers of All Killa No Filla, a British podcast dedicated to exploring the lives of serial killers, found that roughly 85% of listeners are female (Woman’s Hour). BBC Radio 4’s Woman’s Hour considered why their listeners consisted mostly of women, and invited Dr. Gemma Flynn, a criminologist at Edinburgh University, and Rachel Fairburn, co-host of the famous podcast, to explain their theories. Dr. Flynn believes that a major explanation for female true crime listeners includes women retaining an extensive fear of crime. According to Fairburn, “women love true crime because pretty much from the time that we’re very small, we’re told to be careful, look after ourselves, watch out for bad people, make sure we get home safely” (Woman’s Hour). The host suggests that society constantly attempts to protect women from danger, instilling in their minds that as long as they’re alone, they can be attacked. Thus, women tend to leave their house with a constant target on their back and safety on their minds, attracting them to true crime out of self-preservation. With the stereotype and widely held belief that women cannot walk alone at night because of possible attacks, women feel the need to protect themselves as much as possible, consuming true crime stories at the top of their list.
The constant fear society holds regarding women as potential victims of brutal crimes stems from the media’s infatuation with blood and murder. According to a 1992 study conducted at SUNY Oswego,mass media “serves as the primary source of information about crime for up to 95% of the general public,” with approximately 50% of news coverage devoted exclusively to crime stories (Mann). With this extensive reporting on crime and violence, Americans fall victim to their availability heuristic, a mental shortcut that relies on immediate examples that come to a person’s mind when thinking of an idea or event. Because of the increased attention presented towards crime on-air, Americans may not believe that the crime rate has actually decreased over the years since all they hear about is murder, rape, and violence when they turn on their televisions. While murder rates decreased by 20% from 1993 to 1996, reporting on murder on television rose by 721%. (Mann). This affects women especially as the constant fear perpetrated by the media regarding crime and murder may be a key reason in females’ attraction towards true crime media.
Now that we understand why women tend to reach for books labeled with the true crime genre, the compelling question needed to be answered is why women romanticize these vile human beings. After the release of Extreme Wicked, Shockingly Evil and Vile, a film on the life of Ted Bundy based on the perspective of his girlfriend, viewers went to Twitter to express their newfound admiration for the ‘misunderstood’ villain. Ted Bundy was portrayed by attractive and talented Zac Efron, only attracting more fans to the Ted Bundy “fandom,” a group of teenage girls infatuated with the killer (Donaldson). Some tweets include: “Love that conservative masculinity #TedBundy,” and “Ted Bundy is so hot… wish he killed me” (via Twitter). The women who romanticize serial killers like Ted Bundy and Charles Manson can be described as having hybristophilia, or sexual arousal “over someone committing an offensive or violent act,” as described by Dr. Katherine Ramsland, a forensic psychology professor at DeSales University. These women admire the idea of being the ‘exception’ for a damaged person; they feel the need to ‘nurture’ and ‘protect’ their powerful and evil lovers. These women fantasize about “changing” the broken part of serial killers; they want to “fix” them; usually, women who admire such behaviors have trouble with conventional relationships due to insecurities. If she dates a serial killer in jail, at least she’ll know where he is all the time (Psychology Today).Additional research indicates that women feel attracted to masculinity and may interpret serial killers’ unchecked aggression as ‘protective’ or ‘manly.’ Women may feel that these attributes will keep them safe and secure, and thus may prefer more violent mates (Perrett).
Whatever may be the reason behind women’s fascination with serial killers, this infatuation proves fatal. When Charles Manson and Ted Bundy awaited death, thousands of female fans lined up, expecting to marry these vicious men, refusing to believe their crimes simply because of their attractiveness (Sutton). The never-ending fame of attractive serial killers depicts the true danger: our inclination as human beings to automatically trust and like attractive people, simply because of their looks. Many women fell prey to Bundy and Manson’s traps simply because they might’ve misjudged them for being kind, respectable people because of their beautiful smiles or bright eyes. Though Netflix and other entertainment providers may attempt to raise awareness of real tragedies, it is important to also consider the danger of awareness. Today’s generation may be too infatuated with Zac Efron’s looks and appearance in Extreme Wicked, Shockingly Evil and Vile to realize that his charm was what allowed many to overlook his apparent misogyny and objectification of women: “Women are possessions… Beings which are subservient, more often than not, to males. Women are merchandise” (Wyman).The tales of these serial killers should serve as a warning to many women, rather than favorable romantic heroes; we really don’t know what people are like behind closed doors. We need to remind ourselves who these serial killers actually are: vile, immoral men disguised as educated, charismatic professionals; they are not compassionate or need protection – they do not feel. We must not grieve or sympathize with men that never existed.
Whyman, Tom. “The Myth of Ted Bundy as a Charming Guy.” The Outline, The Outline, 5 Feb. 2019, theoutline.com/post/7043/ted-bundy-netflix-efron-handsome?zd=1&zi=godwptow.
Yates, Diana. “Women, More than Men, Choose True Crime over Other Violent Nonfiction.” ILLINOIS, 15 Feb. 2010, news.illinois.edu/view/6367/205718.
My phone lies face down on the table beside me, buzzing sporadically, but insistently. I ignore it, fanning myself against the mid-July heat as I attempt to concentrate on an assignment for my summer class. I drum my fingers against the desktop and whisper the words aloud to myself, trying to make sense of the convoluted sentences of the essay as the buzzing continues. What do they want? I think exasperatedly, assuming my friends are simply spamming me with memes from Instagram and funny Tiktoks. As I finish the reading passage and move on to the multiple choice questions that accompany it, I decide to spare a glance at my phone. Expecting to see Instagram direct messages (DMs) and text messages headed by my friends’ familiar usernames and contact names, I am shocked to instead see hundreds of Instagram comment notifications from unfamiliar usernames, all beginning with the common header “[Instagram user] mentioned you in a comment.” My heart racing in anticipation, I open the Instagram app and quickly scroll through my notifications. I had left a comment criticizing France’s April 2021 ban on hijabs (headscarves worn by women for religious reasons) for Muslim women under the age of 18 on a post advertising travel to the Eiffel tower, and now I see that all these comments are in response to mine. Some of them back me up, but others range from applauding France’s actions, to blatantly calling Islam backwards and incompatible with Western civilization, to attacking me as a young Muslim woman myself. I exit the app without bothering to respond to anyone and close my eyes for a second, my heart still pounding as the hate words flash through my mind repeatedly. Like me, young Muslims everywhere are exposed to Islamophobic rhetoric on the social media sites they use most, and chronic exposure to such hate inevitably takes a toll on their mental health. Online hate is not given the same coverage or attention that street-level hate crimes get, but the effects of the former may be exponentially more profound due to the wide reach of users that are present on online platforms. Actions should be taken to limit such hate speech on public platforms like social media to preserve the mental-wellbeing of users that are targeted by these remarks, even if it means limitations on the First Amendment right to free speech.
In a case close to home, a Muslim student recently graduated from my high school in the summer of 2021 and was chosen to deliver a speech at the commencement. In her speech, she advocated for the need for understanding and peaceful coexistence during difficult times, and briefly mentioned the ongoing conflict between Israel and Palestine. This part of the speech incited infuriated outcries from the audience, rude remarks shouting at her to “go back to Pakistan” as she walked off the stage, and the creation of a Facebook group as a space for angry parents to vent and express mildly Islamophobic sentiments. Due to the convenience and ease of access, social media is frequently defaulted to as a platform for these polarizing conversations. Certain social media sites, such as Twitter, are “better-designed,” in a sense, to perpetuate hate speech and to facilitate radicalized expression. Dr. Nigel Harriman, professor at the Harvard T.H Chan School of Public Health, and a group of researchers found that 57% of students that actively used the social media sites Youtube, Instagram, and Snapchat had come across hate speech, and 12% had encountered a stranger that tried to convince them of racist beliefs (this was especially common on Youtube). Additionally, exposure to hate messages was significantly correlated to Twitter use and Houseparty use (Harriman et al., 8531). Twitter is a particularly convenient hotbed for such rhetoric, as victims that come forward to tell their stories to Twitter are simply told to block the hating account or delete their own account. In 2014, Twitter issued a statement claiming that it “cannot stop people from saying offensive, hurtful things on the Internet or on Twitter. But we can take action when content is reported to us that breaks our rules or is illegal” (“Updating Our Rules Against Hateful Conduct”). Twitter more recently updated its rules against hateful content in December 2020:
In July 2019, we expanded our rules againsthateful conduct to include language that dehumanizes others on the basis of religion or caste. In March 2020, we expanded the rule to include language that dehumanizes on the basis of age, disability, or disease. Today, we are further expanding our hateful conduct policy to prohibit language that dehumanizes people on the basis of race, ethnicity, or national origin.
(“Updating Our Rules Against Hateful Conduct”)
Although Twitter has taken some necessary steps to limit hate speech, this form of harassment nonetheless still exists on this and countless other platforms, and more action must be taken to counter this.
As someone that frequents social media sites like Instagram and Facebook, I understand how detrimental the algorithms themselves can be to one’s self-esteem, but coupled with exposure to hate speech, mental health for those targeted is more likely to plummet. Although I ultimately ignored the hate comments on Instagram under the post about France, the occurrence bothered me for several days afterward, leaving me anxious, unsettled, and dealing with mild sleep difficulties to the point where I deleted Instagram for a few months. Research by Dr. Helena Hansen at NYU Langone found that victims of online hate speech are found to have elevated levels of the stress hormone cortisol, leading them to exhibit a blunted stress response as well as higher rates of anxiety, sleep difficulties, and substance use (Hansen et al. 929). Dr. Brianna Hunt at Wilfrid Laurier University found that exposure to Islamophobic rhetoric is also a predictor of social isolation and loneliness, particularly among Muslim women in Waterloo, Canada. Furthermore, the dehumanizing aspect of hate speech also incites conflicts of identity in Muslim women of color, who feel that neither their religious nor their racial ingroups accept them fully, calling for the need to address mental health for more complex cases of intersectionality as well (Hunt et al.).
In an effort to mitigate the destructive effects of hate speech on mental health, individuals have advocated for limiting such speech, but opponents of these limitations have expressed their concerns and dissatisfaction with this movement. In the 2017 case Matal v. Tam, the Supreme Court of the United States ruled that hate speech, like regular speech, is protected under the First Amendment under the justification that “giving offense is a viewpoint” (as long as it does not directly incite violence) (Beausoleil 829). Thus, individuals opposing limitation of hate speech on social media argue that doing so would be an infringement on their First Amendment right. There is also the danger that limitations of this sort would be a step in the direction of mass surveillance and abuse of power, ultimately resulting in a power dynamic of large digital companies﹣and potentially the government﹣in stifling any and all dissent (Beausoleil 2124). Other supporting evidence includes the notion that some exposure to counter speech is needed for the development of stable mental health and that various studies have shown that limitation of hate speech does not correlate to improved social equality (Beausoleil 2125). In fact, Dr. Stephen Newman of York University points out that expression of this sort of dialogue may be integral to human personality development, and that exposure to robust forms of speech may actually improve societal dynamics by influencing democratic policy (Newman). Lastly, there is limited existing literature proving that hate speech limitation is beneficial, as regulations of this magnitude have not been implemented anywhere yet. Thus, this argument is largely based on studies that have shown the harmful effects of hate speech.
In a growing digital age, where social media use is a part of daily life for adolescents, young adults, and even middle aged individuals, chronic exposure to hate speech such as Islamophobic rhetoric cannot be tolerated. The longer online sites and social media platforms delay addressing such sentiments, the more widespread and normalized they will become and the more detrimental the effects will be on affected individuals’ mental health. In regards to opponents’ concerns over First Amendment compromise, the First Amendment cannot be applied perfectly to the digital age, which allows for unprecedented and unanticipated reach of communication across borders, continents, and time, as posts can always be viewed and interpreted so long as they are not deleted (Beausoleil 2127). Restrictions on the right to free speech are warranted in this case, where the mental health of countless targeted individuals on a global scale are at stake. To limit the likelihood that these companies abuse their extended powers of speech limitation, restrictions should be placed on the companies’ extent of power as well (ie. restrictions should be placed on the restrictions). Rather than immediately deleting all posts and comments including hateful rhetoric (which may be impractical), social media platforms should specifically aim to disband or deactivate groups, chat rooms, and accounts specifically devoted to or frequently posting Islamophobic﹣and other hateful﹣rhetoric. On particular posts where the comment section becomes overwhelmingly belligerent and hate-fueled, social media platforms should either delete the post, delete the inflammatory comments, or disable the comment section entirely. Lastly, these social media platforms should issue public statements against hate speech like Twitter did, include them explicitly in their terms and conditions of use, and send automated warnings to users who violate conduct rules multiple times with the intent of suspending their accounts if hateful activity continues.
Ideally, the extent to which media companies can regulate inflammatory speech should be overseen by the federal government. However, complications may arise due to matters of jurisdiction: for example, the US government may have limited say on regulation of content posted on the social media platform TikTok, as this company was founded in China. Thus, for the time being, regulations should remain on a company-to-company basis. In the short-run, it can be expected that consumer use and feedback will let companies know how effective and acceptable their policies are.
Though many praise the advent of cyberspaces and the beginning of the digital era as a way of bringing the world closer together with connections never known before, it is difficult to fathom how connected we really are amidst the divisive and discriminatory rhetoric that is often perpetuated on the very same platforms. Hate speech is present in several different forms, including anti-Semitism, racism, homophobia, gender discrimination, and prejudice against disabled individuals. As a Muslim woman, the recent increase in Islamophobic sentiments on social media have made me realize how pervasive their effects on young Muslims’ mental health are. Therefore, I strongly encourage social media platforms to limit hateful speech and promote civil and constructive dialogue instead using the methods outlined above, even if it means a slight compromise on First Amendment rights. By merely limiting and not completely eradicating hate speech, the extent of social media companies’ power is kept in check and the potential societal benefits of exposure to antagonistic speech mentioned previously may still be experienced. Taking actions such as deleting the Instagram post about France with the barrage of inflammatory comments would be steps in the direction of greater coexistence as the Muslim high school graduate’s speech earnestly called for and promoting the benefits of global connection that the digital era originally promised.
Works Cited
Beausoleil, Lauren. “Free, Hateful, and Posted: Rethinking First Amendment Protection of Hate Speech in a Social Media World.” Boston College Law Review, vol. 60, no. 7, 2019, pp. 2101–2144.
Hansen, Helena, et al. “Alleviating the Mental Health Burden of Structural Discrimination and Hate Crimes: The Role of Psychiatrists.” The American Journal of Psychiatry, vol. 175, no. 10, 2018, pp. 929–933, doi:10.1176/appi.ajp.2018.17080891.
Harriman, Nigel, et al. “Youth Exposure to Hate in the Online Space: An Exploratory Analysis.” International Journal of Environmental Research and Public Health, vol. 17, no. 22, 2020, 8531, doi:10.3390/ijerph17228531.
Hunt, Brianna, et al. “The Muslimah Project: A Collaborative Inquiry into Discrimination and Muslim Women’s Mental Health in a Canadian Context.” American Journal of Community Psychology, vol. 66, no. 3-4, 2020, pp. 358–369, doi:10.1002/ajcp.12450.
Newman, Stephen L. “Finding the Harm in Hate Speech: An Argument Against Censorship.” Canadian Journal of Political Science, vol. 50, no. 3, 2017, pp. 679–697, https://doi.org/10.1017/S0008423916001219.
This essay examines maternal healthcare practitioners’ perspectives about and experiences with incorporating sex- and gender-based medicine (SGBM) into healthcare training at Stony Brook University, a leading medical institute in the United States. SGBM refers to the style of clinical practice that accounts for the ways in which biological sex characteristics and social constructions of gender affect healthcare outcomes. This method is particularly critical for women’s and reproductive healthcare providers because they routinely treat patients that experience gender and its unique interactions with other sociocultural factors. Within the wide range of literature discussing the need to integrate an SGBM lens into medical education, only a handful of scholars have examined why it is so difficult to actually accomplish. Building on this emerging body of evaluation research, I conducted several oral interviews with faculty at the Stony Brook Schools of Medicine and Nursing, discussing how they have reacted to this relatively new but essential field of medicine from the early 1990’s to today. The university has recently claimed that its health institutions are progressive both politically and practically, but I argue that “progressive” is an exaggerated description. Based on the interviews, instructors continue to face institutional as well as logistical barriers to incorporating an intersectional gender lens into their didactic and practical curricula. Furthermore, this case study offers insight into how practitioners can improve the ways they currently teach gender in order to produce more equity-conscious and diversity-respecting maternal care providers.
Full Text
“Learning is not attained by chance, it must be sought for with ardor and diligence.”
– Abigail Adams (“Abigail Adams,” 2019).
Introduction
Medicine, particularly medical education, has historically ignored the humanities and social sciences, especially intersectional gender and sexuality studies. Maternal and reproductive health scholarship that actually includes women as its subjects and researchers did not emerge until the women’s health movement rooted itself in American academia just over two decades ago. However, the field’s first fifteen years or so focused on biology-based differences between men and women with minimal regard for any individuals identifying outside the cisgender, heterosexual norm. Gender and sexuality only entered the conversation in the last five years, and even now, intersectionality is barely acknowledged. Medicine continues to primarily use the additive model, which considers various forms of oppression (sexism, racism, ableism, etc.) separately rather than examining how they operate inseparably (Kang et al., 2017).
And yet, intersectionality is more important than ever before, especially in the United States. The number of Americans who identify as a person of color and/or LGBTQ* grows every day (Jones et al., 2021; Jones, 2021). Therefore, it is imperative that medical providers understand how to treat their patients with respect for diversity in all its forms. As with any sustainable change, the process of removing heteronormativity from medical practices must begin with medical training. In this essay, I aim to provide a snapshot of where American medical education stands on the inclusivity stage. I will accomplish this by examining maternal, reproductive, and family healthcare practitioners’ perspectives about and experiences with incorporating sex- and gender-based medicine (SGBM) into education at Stony Brook University, a leading medical institute in the United States. These perspectives reflect the larger institution’s state of inclusiveness and progressiveness.
For reference, SGBM refers to the style of clinical practice that accounts for the ways in which biological sex characteristics and social constructions of gender affect healthcare outcomes. This method is particularly critical for women’s and reproductive healthcare providers because they routinely treat patients that experience gender and its unique interactions with other sociocultural factors. Building on this emerging body of evaluation research, I conducted several oral interviews with faculty at the Stony Brook Schools of Medicine and Nursing, discussing how they have reacted to this relatively new but essential field of medicine from the early 1990’s to today.
Stony Brook University has recently emphasized its “progressive” approach to healthcare, especially regarding women’s and LGBTQ* populations. In response, I argue that while the Schools of Medicine and Nursing are certainly more aware of SGBM than they were two decades ago, the university still lacks clear intersectional gender- and sexuality-inclusive training and approaches the education they do have in a non-inclusive, binary way. In this essay, I will provide historical context for my analyses by briefly summarizing key events in the trajectories of feminism, the Women’s Health Movement, and sex- and gender-based medicine (SGBM) in the late twentieth century. I will then conduct an in-depth analysis of my case study research and its implications. Finally, I will conclude by proposing potential ways for practitioners to improve how they currently teach gender in order to produce more equity-conscious and diversity-respecting maternal care providers.
Background
How maternal and reproductive medicine evolved with American politics
When Betty Friedan’s groundbreaking book The Feminine Mystique was published in 1963, America began to realize that many of its women were dissatisfied with simply being housewives (Churchill, 2020). After World War II, women were not especially keen on relinquishing the professional and financial freedoms they had found in the factories while the men were fighting overseas. Simultaneously, the Stonewall Riots in 1969 marked the birth of what is now commonly referred to as the modern LGBTQ* rights movement (Duberman, 1993). In the following decades, both of these marginalized groups would find themselves at the center of the global political and health stages.
Policy and health were particularly inseparable during this era. The 1990s saw what is now known as Third Wave Feminism, placing women’s experience at the center of American politics and “integrat[ing] an ideology of equality and female empowerment into the very fiber of [American] life” (Walker 400, 1992).Women delayed marriage into their mid-twenties, felt sexually liberated, and entered male-dominated careers (Yarrow, 2018).Yet, the fight for equality raged on in the political and medical arenas, clashing in landmark health-related historical events such as the Anita Hill sexual harassment hearings (Gross, 2021), Planned Parenthood’s fight against conservatives over abortion rights (Prescott, 2019), and the Violence Against Women Act of 1994 (“History of VAWA”).
In the same decade, the Women’s Health Movement was progressing with full-force activism: reproductive endocrinologist Florence Haseltine co-founded the Society for Advancement of Women’s Health Research in 1989, which helped to pass the Women’s Health Equity Act one year later and created the Office of Research on Women’s Health at the National Institutes of Health. In 1993, following the groundbreaking discovery that the HIV virus can pass from pregnant parent to fetus, Congress required the inclusion of women in NIH-sponsored clinical research trials (Liu and Mager, 2016). Prior to this mandate, women of childbearing age were considered too high-risk to participate in clinical research due to the possibility of pregnancy, severely inhibiting knowledge production about sex and gender in healthcare (Participant 3, 2021). It was these socio-political and medical paradigm shifts within women’s health research that gave rise to what is now referred to as sex- and gender-based medicine (SGBM). Within the wide range of literature discussing the need to integrate an SGBM lens into medical education, only a handful of scholars have examined why it is so difficult to actually accomplish.
How sex- and gender-based medicine was born
In the midst of this emerging field of women’s health intervention evaluation, Lorena Alcalde-Rubio et al. reviews 22 articles that evaluate clinical interventions aimed at “reduc[ing] variability in healthcare,” five of which focus on sexual and reproductive health (Alcalde-Rubio, 2020). The majority of the 22 evaluations supported standardizing protocols as a feasible method of systemic change, which is consistent with the faculty’s opinions during my interviews. However, Alcalde-Rubio’s review does not specify what types of protocols should be standardized and importantly notes that 15 out of the 22 evaluations did not utilize gender perspectives adequately. Further, the review significantly reflects a larger fault in medical academia: researchers often focus too much on the purely clinical aspect of change. When it comes to destabilizing social constructions that are ingrained in us and impact every aspect of human life both inside and outside of medicine, education plays a, if not the most, critical role in producing systemic change. In other words, we cannot fix the problem without addressing its roots. As such, I will primarily address the education aspect that Alcalde-Rubio et al. does not.
A 2005 Dutch study (Verdonk et al.) attempts to explore the potential for long-term change in medical education. Researchers concluded that a lack of guidelines, political ideology conflicts, and the educators’ own levels of dedication contribute to the gap between what should be taught and what was actually being taught. Further, certain factors must be present to successfully incorporate gender into medical training, including faculties’ personal experiences and motivations, practical support, and “executable” proposals for adjustment. This suggests that the Western medical educators were generally aware of the need for gender education in the 1990s, the decade during which many of my interviewees were medically trained here at Stony Brook. However, Verdonk, like many others in the field, conceptualizes gender as binary and essentialist.1 To make any meaningful progress, modern medical educators need to start deconstructing the gender binary and validating identities and sexualities beyond the cisgender, heteronormative ones.
Like Verdonk et al., Mary Rojek and Marjorie Jenkins (2016) examined medical schools, but this time in the United States. They surveyed faculty from medical schools that had already successfully integrated SGBM into their education. Their results suggested “it was important to involve all stakeholders… linking curricula to experiential learning and research. It was important to support faculty by providing them with educational resources” (Rojek and Jenkins, 2016). The majority of schools, though, are still behind in adding a sex- and gender-based lens to formal medical education. My research supports Rojek and Jenkins’ conclusions that formal institutional support is a crucial factor in determining integration success.
Also similar to Verdonk et al.’s case study, Hsing-Chen Yang examined the Eastern (Taiwanese) medical world’s perspectives about gender. Asian beliefs and social norms about gender are significantly different from Western ones, and even between individual Asian cultures themselves. Because Stony Brook’s Renaissance School of Medicine began accepting international applicants in 2014 (Medical School (MD) Applicant Profile, 2021), along with the majority of graduate students across the university identifying as people of color (Stony Brook University Fall Headcount, 2021), it is crucial to consider a diverse set of approaches to medical education. Because patient populations are now increasingly diverse—fueled by immigration and globalization—healthcare providers need to have a basic understanding of how gender functions in different cultures. Yang’s surveys found that healthcare professionals and teachers generally believe that sexism, gender awareness, gender equity, and patriarchy are among the most important to teach but this prioritization is not reflected in practice. However, the study omits two key factors: historical context and sociocultural context. Sexism, gender, and patriarchy have various meanings depending on the patient’s and the provider’s respective backgrounds. Therefore, Yang’s conclusions may be limited to predominantly Asian regions.
To see if Yang’s results holds true in Western medical culture, I came upon a 2010s-era study that revealed that American students also lack sex- and gender-based medical (SGBM) training, Majorie Jenkins et al. (2016) surveyed 1097 medical students across five major medical student organizations in order to examine institutional response to these findings. Jenkins’ survey suggests that while medical students are generally aware of SGBM’s existence, the majority do not receive adequate SGBM education at their respective medical schools. While it provides a solid look at what other American healthcare schools are doing about SGBM in relation to Stony Brook, Jenkins focuses solely on students’ perspectives rather than those of faculty, not accounting for logistical and institutional obstacles instructors face that students may not be aware of. I aim to fill this knowledge gap in this case study.
Methods
Stony Brook University
Stony Brook University (SBU) grew alongside the women’s movement. The university was founded in 1957 (“History and Mission”), and its Renaissance School of Medicine (RSOM) opened in 1971 (“History,” 2019). The RSOM currently houses 25 professional departments, including “Obstetrics and Gynecology,” which is an influential player in university progressive politics (“Departments,” 2019; Participant 5, 2021). One year after the RSOM admitted its first class, the SBU School of Nursing (SON) opened in 1972 (Strategic Plan 2016 to 2021, 2017). Graduate-level programs were gradually added in the following years, and the school’s first doctoral-level program, the Doctor of Nursing Practice (DNP) program, admitted its first cohort in 2007 (Participant 2, 2021). Now, Stony Brook’s Hospital is considered one of the best in the United States and boasts progressive and inclusive practices. This makes it an ideal institution to study the emerging field of sex- and gender-based medicine, especially considering its diverse student and faculty profile.
Sample
While gender undoubtedly affects all areas of health, obstetricians (OBs), gynecologists (GYNs), and nurses typically have the most direct patient contact with populations where gender is uniquely related to healthcare outcome (Participant 5, 2021). For example, maternal care and reproductive care specialists may see pregnant trans patients, same-sex couples with fertility concerns, and Black cisgender women, who have disproportionally higher rates of maternal mortality in the United States (“Working Together,” 2021). For this reason, I individually interviewed a total of six faculty at Stony Brook University, including three OB-GYNs from the Renaissance School of Medicine and three from the School of Nursing. Participants were recruited via email outreach based on whether they attended Stony Brook University for their undergraduate degree, graduate degree(s), residencies/fellowships, or any combination of those three. Each interview was approximately thirty minutes long and conducted over Zoom or phone call between the months of September 2021 and November 2021.
Table A. Participants’ Educational Backgrounds
Participant
Type of Clinician
Highest Degree Earned
Residency
1
Medical doctor
MD*
OB GYN*
2
Nurse practitioner and midwife
DNP*
N/A
3
Pediatric nurse practitioner
Ph.D.*
N/A
4
Family and acute care nurse practitioner
DNP*
N/A
5
Medical doctor
MD
OB GYN*
6
Medical doctor
MD*
OB GYN*
Key DNP – Doctor of Nursing Practice MD – Doctor of Medicine PhD – Doctor of Philosophy *Completed at Stony Brook University
Interview Questions
Educational Background
I asked the participants five main questions about various gender- and sexuality-related topics. The first question asked about the participants’ educational backgrounds, including where they earned their undergraduate degree(s), graduate degree(s), and where they completed their post-doctoral residency and fellowships if applicable.
Gender & sexuality education as a student
The second question asked about the participants’ experiences – or lack thereof – learning about gender as a student, including as a medical or nursing student and graduate-level nursing student or medical resident.
Current gender & sexuality education
The third question asked participants to compare their own student experiences to what current SBU students learn about gender. The fourth question asked about their experiences and opinions about teaching gender as a professor, including what challenges they may face and how they address them.
Institutional support
The fifth question asked participants if the university has offered and/or currently offers opportunities for faculty to further their own knowledge about gender and sexuality in healthcare, and if so, what types of opportunities and how helpful they were.
Results & Discussion
Participants’ own gender and sexuality training
None of the participants had any formal education about gender nor sexuality, with the exception of studying purely biological sex differences, when they were medical/nursing students. All participants received their first clinical degrees (BSN or MD) in the 1990s or early 2000s. At the time, SGBM was just beginning to grow as a legitimate field of medicine and was more commonly referred to as “gender-based biology” (Madsen et al., 2017).
For example, a few of the participants from both the RSOM and SON recalled learning about sex differences in symptom presentation and risk levels for certain conditions, such as the fact that men are more likely to have a heart attack while women typically show less obvious signs of a heart attack like pain similar to that of severe indigestion (Participant 3, 2021). Participant 2 recalled learning absolutely nothing about gender, especially its interactions with race and ethnicity. As a Black woman, she did not feel supported by the School of Nursing while earning her degree. Therefore, diversifying nursing education is particularly important to her, so a tremendous portion of the efforts to update the midwifery curriculum comes directly from her. This aligns with Verdonk’s 2005 findings, where a specific professor of Women’s, Gender and Sexuality Studies was an “important stimulus” and “trigger” person for SGBM integration. For Stony Brook’s midwifery program, Dr. Findeltar-Hines is the “trigger” person.
Another important consideration is that in the 1990’s, patients were often quite hesitant about revealing their gender identity and/or sexuality to practitioners (Participant 6, 2021). Furthermore, gender-affirming care standards, mostly relating to gender-affirming surgeries, did not exist until 1979 (Frey et al., 2017). The first major case study in hormonal puberty blockers, now a major treatment option for transgender, non-binary, and gender non-conforming pediatric patients, was not published until nearly twenty years later in 1998 (Cohen-Kettenis et al., 2011). Clinical progress took decades, and the curricula were trailing far behind as a result. This aligns with the Verdonk et al. case study of the Dutch medical center (2005), in which faculty’s personal experience and motivation was found to be a key factor in ensuring the success of gender education integration. Unlike the Dutch case study, though, Participant 2 acknowledges that gender exists on a spectrum and does not conceptualize it in mere binary terms, perhaps contributing to the Midwifery program’s progressive success in recent years. According to Participant 2, the program’s instructors have created a trans patient case study, use gender-neutral pronouns whenever possible, and are currently working on implementing gender/sexuality- and race-specific lectures.
This level of dedication to building gender-inclusive training is not consistent across the nursing and medical schools, however. While some participants recalled learning about “special populations” (Participant 4, 2021), which include trans and gay patients, it was from a very “cisgendered” perspective (Participant 1, 2021). This special population education was also added to the curriculum out of political pressure rather than student/faculty motivation. In the 1990s, HIV and AIDS awareness skyrocketed to the top of major health institutions’ priority list as the AIDS epidemic entered its “Middle Era” and gained international attention (Durvasula, 2018). This increased public health attention to women’s and reproductive health disparities, but commonly used terminology like the “4H Club [homosexuals, hemophilliacs, heroin users, and Haitians]” were homophobic and racist, essentially doing the opposite of increasing gender and sexuality awareness (Participant 3, 2021). In fact, prior to the AIDS epidemic, those who identified as female were prohibited from participating in medical research, so it’s not surprising that health practitioners and academics ignored gender education.
What current SBU students learn
Current SBU students learn more than participants’ did but the integration of gender and sexuality into the curriculum is slow. Challenges include time constraints (Participant 1, 2021), disparities in instructors’ own knowledge about the topics (Participant 1, 2021), and resistance from more traditional faculty (Participant 2, 2021). Ultimately, it is up to individual faculty to decide how much they want to adjust their curricula to include diversity education.
The Renaissance School of Medicine did not start internally pushing for inclusive education until two to three years ago (Participant 1, 2021; Participant 6, 2021), and since then, progress has been very slow. The majority of interviewees recognized the need for specialized gay and trans* education, but that was about the extent of their reported knowledge. Only one or two faculty mentioned non-binary and gender-nonconforming patients (Lian, 2021; Participant 3, 2021), and one mentioned the relationship between race, socioeconomic/citizenship status, and healthcare outcomes (Participant 6, 2021). None offered evidence of education that focuses on the vast variety of other gender and sexuality spectrums, including sexualities that are not strictly straight/gay/bisexual. Only one doctor mentioned how clinical placement affected patient populations. For example, attending physicians working at a Flushing, NY clinic might see more Asian patients while someone working in a “resident clinic” would typically see patients in less privileged socioeconomic groups. The resident clinics have more Hispanic and non-English speaking patients “by default” (Participant 6, 2021).
It is also worth noting that while a few participants mentioned race, gender, sexuality, socioeconomic status, and ability status separately, it was evident that all of them viewed gender and sexuality using an additive lens. The additive model considers systems of oppression to be individual entities rather than structures that cannot operate without one another. Intersectionality was undoubtedly an unfamiliar term, so interviewees were largely unable to answer questions about the intersections of identity factors like gender and sexuality. A potential cause of this issue is the lack of precise terminology in the broader field itself (Madsen, 2017).
The School of Nursing, however, began adding diversity and inclusion to its branding in 2017, which, coincidentally, is the same year the Midwifery Program appointed the first woman of color as its Director. In its academic success goals, the Strategic Plan 2016 to 2021 (2017) specifically lists “recruit diverse nursing faculty” and “expose [nursing students] to global health and healthcare disparities.” Since then, the midwifery program has been adapting lectures to use more inclusive terminology, such as saying “patient” instead of “woman” and “parent” instead of “mother.” Additionally, the program was the first in the SON to add a transgender-specific case study to the curriculum. As the program director noted in her interview, “Education is always evolving… We [educators] have to stay creative and innovative in order to get the basic education things that we want learned [by the students]” (Participant 2, 2021). This is both in agreement and in direct contrast with Yang’s Taiwanese survey of healthcare professionals and teachers regarding gender education expectations. Yang claimed that workplace sexism is a primary cause of the disparity between what instructors believe should be taught and what is actually taught about gender. She also argued that this same sexism prevents educators from viewing gender as a human issue rather than a “woman issue” (Yang, 2020). Participant 2 suggests that all educators must address gender education, including the traditionalists, and simultaneously expresses that workplace discrimination is not an excuse for lack of progress.
All faculty are required to retain clinical practice while teaching, and all participants hold additional leadership positions within their respective schools (Participant 4, 2021). Combined with minimal access to formal training, some traditionalists would say that faculty simply don’t have the time to educate themselves about gender so it is much harder for them to teach it (Participant 1, 2021). However, integration does not necessarily need to involve revamping the entire curriculum (Participant 3, 2021). Faculty could also incorporate gender diversity education into existing training, such as making a simulated patient a woman of color or a child with two mothers. Additionally, instructors could use case studies to emphasize a wide variety of lessons, such as Participant 2’s pediatric case study with a transgender (assigned female at birth) patient named “Timmy” (2021). This case study provides opportunities to practice using proper gender pronouns, learn about hormonal gender affirming treatments, and how to interact with parents of gender-diverse children. Across all interviews, participants said that they would like to improve the time dedicated to gender and sexuality education, so the motivation is there. These sentiments align with those of the students that Jenkins et al. surveyed in 2005, meaning formal course offerings have not improved much since then.
According to the participants, the students are the main driving force behind integrating gender and sexuality training into their healthcare studies. This result was also expected based on the Jenkins et al. survey (2005). On top of being very receptive and eager to learn about diversity, they even provide feedback asking to learn more (Participant 2, 2021; Participant 1, 2021; Participant 4, 2021). Depending on clinical placements, students also have the opportunity to interact with diverse patient populations (Participant 4, 2021), and at Stony Brook Hospital, residents consistently see high levels of diversity (Participant 5, 2021; Participant 1, 2021). While not all healthcare practitioners will work directly with gender-diverse patients, it is still extremely important for all medical providers to understand and be able to apply gender-inclusive theories. According to a recent 2021 Gallup poll, 5.6% of American adults, and one in six adults in Generation Z alone, identify as LGBT (Jones, 2021). Furthermore, the U.S. Census estimated that in 2019, over 36% of women were women of color, and this proportion is projected to grow to over 55% by 2060 (“Women of Color in the United States,” 2021). These statistics are particularly relevant to maternal and reproductive healthcare; therefore, it is critical that these healthcare providers are trained, at least on a basic level, in gender and sexuality studies (Participant 5, 2021).
Institutional support
Based on Verdonk’s 2005 study of a Dutch medical center, institutional support must be present in order to successfully incorporate sex- and gender-based education into healthcare curricula. This may be in the form of financial resources, guest lecture support, accessible educational resources, and visual/presentation support (Verdonk, 2005). With this in mind, I asked participants about how Stony Brook University supports its healthcare faculty in diversifying the curricula, if at all.
Using a binary gender lens
SBU as an institution provides some structured learning opportunities for faculty specifically about using an intersectional gender lens when practicing healthcare, but students and faculty want more. In terms of gender education, because the topic is so relevant to daily patient care for OB GYNs, a few formal lectures have been offered, and OB GYN residents discuss gender- and sexuality- related cases during grand rounds (Participant 5, 2021). For medical students, as of 2020, all SBU medical and dental students are required to take a “Transition to Medical and Dental School” course that talks about gender and diversity issues (Participant 1, 2021)
Using a heteronormativeLGBTQ* lens
In terms of LGBTQ* inclusivity, two of SBU’s major medical institutions, Stony Brook Medical Center and Stony Brook Southampton Hospital, scored a 100/100 on the Human Rights Campaign (HRC) Foundation’s 2020 Healthcare Equity Index [HEI] and were named LGBTQ Healthcare Equality Leaders (Healthcare Inequality Index 2020).2 According to Stony Brook, “[t]he HRC is the largest national lesbian, gay, bisexual, transgender and queer civil rights organization” (“Health Equality Leader,” 2021). However, the HRC has received a substantial amount of criticism for, despite its claims, failing to represent and advocate for LGBTQ* folks of color. Much of this controversy surrounded the Don’t Ask, Don’t Tell Repeal Act of 2010 (“H.R.2965,” 2010). In the months leading up to its official passing, the HRC used a disabled, gay veteran of color to promote fake inclusivity while it simultaneously “profited from the practice of diversity management” (Montegary, 2015). Further, the HRC has been called “cisgenderist” and white supremacist for several years (Johnson, 2011; Rosen, 2021). As such, their HEI rating may not have as much practical weight as Stony Brook claims.
Stony Brook University released an LGBTQ+ Health Needs survey in early summer 2021 and received over 1,218 responses from Long Island, NY residents as of September 30th, 2021. Its purpose is to “provide information critically needed by healthcare providers, social service providers, government officials and public health staff to expand service offerings and serve as effective advocates for LGBTQ+ people” (“LGBTQ+ Health Needs Survey”). Moreover, the survey was made available in both English and Spanish, increasing access to non-English speakers. Suffolk County alone is 20% Hispanic/Latinx, according to the U.S. Census Bureau estimates (“Quick Facts”).
Both the Stony Brook Medicine [SBM] and the School of Nursing [SON] have recently created committees to educate practitioners and spread awareness about gender-informed care. The SBM LGBTQ* advisor committee meets monthly and aims to establish a set of priorities for LGBTQ* patient care, as well as create a more welcoming environment for patients, practitioners, and staff (“Two Stony Brook Hospitals;” Participant 1, 2021). Additionally, the SON’s brand new IDEA committee [Inclusion, Diversity, Equity, and Access] aims to use student feedback to build a more inclusive learning environment (Participant 4, 2021; Participant 3, 2021). Faculty veterans accustomed to traditional academic politics may argue that committees are a poor use of resources, especially in higher education; however, as university administration researcher David Farris writes in “Not Another Committee” (2017), with regular communication, perceived equality among members, and actively focused leaders, committees can actually be quite effective. Nonetheless, it is still important to note that the learning opportunities produced by these committees, particularly at Stony Brook, are created for clinician audiences and are less advertised to didactic instructors (Participant 1, 2021).
Hiding behind generalized health inequity
Pre-COVID, nursing faculty went on a few retreats that focused on diversity inclusiveness, but it was addressed in a very general manner (Participant 4, 2021). Recently, Stony Brook Medicine ran a two-day conference entitled “The Long March to Equity,” which covered general healthcare disparities and their historical trajectories into modern day medicine (Participant 3, 2021). This was the only example mentioned by multiple participants, and I was unable to find any other examples.
One OB-GYN did mention Women’s Health Day, an annual conference at the Renaissance School of Medicine that focuses on various health issues (cardiovascular, eyesight, muscle, breast cancer, etc.) and is exclusively targeted at an all-female audience (Participant 6, 2021; “Women’s Health Day,” 2019). This participant noted that the OB-GYN department also hosts a women’s health clinic on the same day at which anyone can get a routine check-up for free. The department has also started a bi-weekly clinic that provides discounted services for uninsured patients (Participant 6, 2021). However, she also explained that basic needs such as transportation already inhibit many of their regular patients from accessing necessary healthcare appointments. While treating women for free or at lower rates is somewhat helpful, it does not address the issue of inequitable access in an intersectional way; essentially, these clinics are just a Band-Aid solution to a deeper, more complex problem.
Distinct differences between medical and nursing education
The next result I will discuss was unexpected but certainly worth noting. I found clear differences between the perspectives/openness of the medical doctors and nurses. While the medical and nursing models have been known to be incredibly separate for decades (Reed and Watson, 1994), I was surprised by how much the models impacted the providers’ perspectives on sex- and gender-based medicine. For reference, the medical model focuses on “diagnosis, treatment, and cure” and has been widely criticized for its “narrow and unsatisfactory view (Reed and Watson, 1994). On the other hand, the nursing model “offers a more humanistic approach to patient care” (Reed and Watson, 1994).
The Medical Model’s Shortcoming
During the interviews, OB-GYNs consistently steered their responses towards healthcare outcomes, while I found the important connection between education and patient experience to be missing. For example, medical doctor participants mentioned “sobering” maternal mortality statistics, grand rounds3 (Participant 5, 2021), and student feedback being important (Participant 1, 2021), but only one explicitly said they prioritized making patients “feel more comfortable… and heard” (Participant 5, 2021). Yet, is the entire reason for improving medical education to benefit the patients?
Additionally, all three of the OB-GYNs discussed referrals4 as a way to support gender- and sexuality-based diversity. While having and being knowledgeable about sufficient resources is absolutely necessary, it does not address the alarming fact that many maternal and reproductive care providers are entirely unfamiliar with the concepts of intersectionality and non-binary gender and sexuality spectrums. Patients should not need to see another doctor in order to be treated with bare-minimal respect and dignity.
The Nursing Model’s Humility
On the contrary, nursing faculty were much more open to discussing how their personal experiences and medical training affects the quality of care they deliver. For example, Participant 3 took a few gender studies courses during her undergraduate career at Stony Brook, which exposed her to “thinking about other cultures, other health belief systems that wasn’t just coming out of a textbook” (2021). This, she said, impacted both the way she teaches and the way she cares for her queer5 patients, particularly helping her grasp new concepts like non-binary genders and different cultural understandings of disability. Here, the connection between the importance of inclusive education and patient experience is clear. Further, Participant 4 explained how crucial it is for students to work with diverse patient populations during school so that when they enter the workforce as licensed providers, they will already have achieved at least a basic level of intercultural competence.
Faculty diversity
One final point I must discuss is that all six participants identified as women, and four identified as women of color (see Table A on page 9). This sample is not representative of the Renaissance School of Medicine’s and School of Nursing’s faculty at all. The School of Medicine’s Obstetrics and Gynecology department has 42 physician faculty, of which only 13 (about 30%) are women of color. Furthermore, not a single woman is a full professor (with tenure). The department Director and Chair, the two highest leadership positions in the department, are also both white men (“Our Providers,” 2021). Within the School of Nursing, there are 32 faculty, of which 27 (about 84%) are white women and 4 (12.5%) are women of color. There is only one woman of color who holds a director-level position (“Faculty & Staff Directory,” 2021). It seems, then, that the School of Nursing has not yet met its goal to “Recruit diverse nursing faculty” (Strategic Plan 2016 to 2021, 2017).
With these numbers in mind, it is not surprising that Stony Brook University is lagging behind when it comes to incorporating SGBM into healthcare training. The key “trigger person” suggested by Verdonk’s 2005 study is hardly present, which may be why the Midwifery Program is the most progressive program within the School of Nursing (Participant 2, 2021). Verdonk also notes that personal experiences are significant contributors to SGBM’s successful incorporation into medical education (2005). Therefore, because the School of Medicine’s OB-GYN department has two white men occupying its highest leadership positions, and because the School of Nursing only has one woman of color in a leadership position, gender-inclusive training may be extremely difficult to accomplish with the existing faculty structure.
Conclusion
In summary, when the participants, the majority of whom were initially medically trained in the late 1990s to early 2000s, were students, they did not receive any education about SGBM with the exception of purely medicalized topics. Today, Stony Brook medical and nursing students are taught more gender-inclusive curricula but not as much as faculty nor students would like. Participants expressed facing challenges such as finding time to create new content, lacking personal knowledge and familiarity with SGBM, and lack of institutional support in the form of formal, specific training opportunities. Overall, Stony Brook’s “progressive” practices and curricula continue to use a heteronormative lens and show no intentions of trying to dismantle it.
This case study provides a snapshot of the American medical system, which currently faces discrimination and disparities on both clinical and educational fronts. With more Americans openly identifying as LGBTQ* than ever (Jones, 2021), and with populations of color continuing to grow (Jones et al., 2021), addressing gender- and sexuality-based healthcare disparities is an essential piece to improving the health of the nation. If the COVID-19 pandemic has shown us anything, it’s that we are in a deep crisis, and we have been for decades, leaving marginalized groups with inexcusably inequitable care. One of the most effective ways to produce long-term, sustainable change is by educating future generations of providers. This is why it is so important to ensure our healthcare students are receiving, at bare minimum, adequate training on these topics.
Potential ways to improve SGBM education and ensure competency is 1) provide formal, structured training for educators; 2) incorporate SGBM into the didactic and clinical curricula using updated lectures, new case studies, more diverse patient populations, and inclusive simulations; 3) appoint more (qualified) individuals from marginalized groups to leadership positions; 4) allot more funding to gender- and sexuality-inclusive educational initiatives; and 5) continuously assess, collect feedback, and adjust accordingly.
To form a more robust understanding of the medical educators’ attitudes towards SGBM education, future research could involve more individual case studies of academic medical institutions and/or comparing multiple universities. Faculty and student demographics differ between schools and geographic regions, which may affect attitudes as well as financial and socio-political ability to incorporate SGBM into formal medical education.
Footnotes
1 Essentialists believe that certain groups (categorized by race and sex especially) have traits and behaviors that are determined by biological factors. Gender essentialism inherently supports gender inequality by viewing gender as a binary concept, i.e. man versus woman (Hepburn).
2 HEI LGBTQ scores were calculated based on four major criteria: 1) quality LGBTQ patient-centered care, 2) “Patient Services and Support,” 3) “Employee Benefits and Policies” including “transgender inclusive healthcare benefits,” and 4) Patient and Community Engagement” (Healthcare Inequality Index 2020 14).
3 “A grand round is a formal meeting at which physicians discuss the clinical case of one or more patients. Grand rounds originated as part of residency training wherein new information was taught and clinical reasoning skills were enhanced. Grand rounds today are an integral component of medical education” (Stöppler, 2021).
4 A referral is when a healthcare provider does not have sufficient expertise in a particular field and suggests that the patient see a more knowledgeable specialist in that field (“Referral,” 2021).
5 Here, I use the term “queer” to mean “not aligning with the norm” rather than the more conventional “non-heterosexual” meaning.
Acknowledgements & Disclosures
Thank you to Liz Montegary for providing guidance for my research process, and thank you to all faculty who interviewed with me. This research was not funded in any way by any institution and was a fully independent project.
“ACME Accredited Programs.” American College of Nurse-Midwives. portal.midwife.org/education/accredited-programs?reload=timezone. Accessed 14 Oct. 2021.
Alcalde-Rubio, Lorena, et al. “Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice.” International Journal for Equity in Health, vol. 19, 2020. doi.org/10.1186/s12939-020-01283-4.
Basmah, Safdar, et al. “Integrating Sex and Gender into an Interprofessional Curriculum: Workshop Proceedings from the 2018 Sex and Gender Health Education Summit.” Journal of Women’s Health, vol. 28, no. 12, 2019, pp. 1737–1742. doi:10.1089%2Fjwh.2018.7339.
Cohen-Ketenis, Peggy, et al. “Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up.” Archives of Sexual Behavior, vol. 40, no. 4, 2011, pp. 843–847. doi:10.1007/s10508-011-9758-9.
“Departments.” Renaissance School of Medicine, 2019, renaissance.stonybrookmedicine.edu/about/departments.
Healthcare Equality Index 2020. Human Rights Campaign Foundation, 2020, hrc-prod-requests.s3-us-west-2.amazonaws.com/resources/HEI-2020-FinalReport.pdf?mtime=20200830220807&focal=none.
Jenkins, Marjorie, et al. “Sex and Gender in Medical Education: A National Student Survey.” Biology of Sex Differences, vol. 7, no. 1, 2016. doi:10.1186/s13293-016-0094-6.
Johnson, Karlee. “Equality for some: A critique of the Human Rights Campaign.” Daily Sundial, 9 Oct. 2011, sundial.csun.edu/45167/opinions/equality-for-some-a-critique-of-the-human-rights-campaign/.
Jones, Jeffrey. “LGBT Identification Rises to 5.6% in Latest U.S. Estimate.” Gallup News, 24 Feb. 2021, news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx.
Liu, Katherine, and Natalie Dipietro Mager. “Women’s involvement in clinical trials: historical perspective and future implications.” Pharmacy Practice (Granada), vol. 14, no. 1, 2016. doi:10.18549/PharmPract.2016.01.708.
Madsen, Tracy, et al. “Sex- and Gender-Based Medicine: The Need for Precise Terminology.” Gender and the Genome, vol. 1, no. 3, 2017, pp. 122–128. doi.org/10.1089/gg.2017.0005.
Montegary, Liz. “Militarizing US Homonormativities: The Making of “Ready, Willing, and Able” Gay Citizens.” Signs: Journal of Women in Culture and Society, vol. 40, no. 4, 2015, pp. 891–915. doi:10.1086/680333.
Prescott, Heather. “We Must Not Allow a Contraception Gap: Planned Parenthood’s Campaign for New Birth Control and Feminist Health Activism in the 1990s.” Technology and Culture, vol. 60, no. 3, 2019, pp. 816–832. doi:10.1353/tech.2019.0074.
Reed, Janice, and Don Watson. “The Impact of the Medical Model on Nursing Practice and Assessment.” International Journal of Nursing Studies, vol. 31, no. 1, 1994, pp. 57–66. doi:10.1016/0020-7489(94)90007-8
Rojek, Mary, and Marjorie Jenkins. “Improving Medical Education Using a Sex- and Gender-Based Medicine Lens.” Journal of Women’s Health, vol. 25, no. 10, 2016, pp. 985–989. doi:10.1089/jwh.2016.5948.
Verdonk, Petra, et al. “Integrating Gender into a Basic Medical Curriculum.” Medical Education, vol. 39, no. 11, 2005, pp. 1118–1125. doi:10.1111/j.1365-2929.2005.02318.x.
Walker, Rebecca. “Becoming the Third Wave.” 1992. The Essential Feminist Reader, edited by Estelle Freedman, New York : Modern Library, 2007, pp. 397–401.
Yang, Hsing-Chen. “What Should Be Taught and What Is Taught: Integrating Gender into Medical and Health Professions Education for Medical and Nursing Students.” International Journal Environmental Research and Public Health, vol. 17, no. 18, 2020. doi:10.3390/ijerph17186555.
Yarrow, Allison. “How the ‘90s Tricked Women Into thinking They’d Gained Gender Equality.” TIME, 13 June 2018, time.com/5310256/90s-gender-equality-progress/.
SBU Brooklogue 