Editorial

Who says we’re all equal?: Gender as an issue for nurses and nursing care

Paula McGee

PP: 098 - 102

Article Text

Welcome to this special collection of papers about gender and nursing. Developing this collection has not been an easy task. Nurses currently seem remarkably reluctant to address gender, either as an issue in patient care or within their own profession. This seems rather strange considering the number of reports about health inequalities in which gender plays a well-documented part (see for example Longinotto & Ayisi 2005; UNICEF 2008, 2009; WHO 2008a). Despite the many advances in health care, there remain marked differences in the ways in which men and women experience their health and the extent to which services meet their particular needs. While these differences are, in part, physiological in origin, they also reflect the social construction of gender roles: each society's ideas about how men and women should behave, their rights and responsibilities, their status and the exercise of power. In most societies women have lower social status than men and less control over their lives particularly if they are illiterate (UNICEF 2009; WHO 2002). To give just a few examples, global health trends indicate that women are far more likely than men to suffer from anxiety, depression and eating disorders; poverty, forced marriage, unwanted abortions and violence compound their disadvantages (Uddin 2006; UNICEF 2009; WHO 2002). The incidence of HIV/AIDS has risen sharply among young women especially in sub-Saharan Africa, the worst affected area (WHO 2008a). Ignorance about their own bodies and lack of access to education linked with early marriage to men who are likely to be much older and have had multiple sexual partners, all increase the risk of sexually transmitted disease for girls and young women (WHO 2003). While there is some evidence of change in risky sexual behaviour among men, women's lower social status still makes it impossible 'to negotiate safe sex practices with their partners' (and) 'make HIV infection a risk even in women who have only had one partner in their entire lives' (WHO 2003, p.2; WHO 2008a).

Breast cancer is the most common cause of death from cancer among women and 'there is sufficient evidence to show that mammography screening among women aged 50-69 years could reduce mortality from breast cancer by 15-25%' (WHO 2008b, p.22) yet the uptake of screening seems to be linked to wealth. In rich and poor countries, it is the wealthiest women who make the most use of mammography screening (WHO 2008b). While there is no direct link with education and status, it is quite possible that wealthy women have both the education and the status to enable them to take advantage of screening programmes.

Finally, maternal mortality remains unacceptably high in developing countries where women are 300 times more likely than their counterparts in the developed world, to die from treatable complications such as thrombosis or ectopic pregnancy. Those who survive are more likely to be left with fistulae and continence problems that, whilst not physically life threatening, bring stigma and social death that could easily be avoided with skilled maternity care (UNICEF 2009).

Health inequalities among men present a different picture. On average, men's lives are shorter than women's. Life expectancy for both genders has increased worldwide, though in some instances improvements are very slight. In Eastern Europe, for instance, life expectancy for men and women has increased from 64.2 years in 1950 to 67.8 years in 2005 but men die approximately 13 years earlier than women. Almost half these deaths are attributable to cardiovascular disease and accidents account for a further 20%; the remaining causes being infections and cancer (WHO 2008a).

Urological cancers account for almost one third of all cancers among men. Black African Americans appear to be particularly prone to prostate cancer with an incidence of 185 per 100,000 but it is also common among white Americans as well as New Zealanders and in parts of Austria (Haas, Delongchamps, Brawley, Wang, & de la Roza 2008). In contrast, it is rare among Chinese and Taiwanese men but, despite research, the aetiology of the disease and these variations in incidence are not well understood (WHO 2008b). Cultural norms that regard illness among men as a sign of weakness discourage them from seeking help early. Ignorance about the body may be similarly construed and thus deter men from accessing information about health. A review of attempts at HIV prevention is particularly instructive on this issue. Cultural norms that encourage men to engage in multiple sexual relationships as a means of demonstrating their virility and fertility increase the risk of infection (WHO 2003). Such norms encourage the belief that a real man sleeps around and will not be infected; if he is, it must be someone else's fault, rarely his own.

These examples indicate that gender inequalities raise multiple challenges for nurses as 'a critical component of the infrastructure for providing essential health services' because 'nursing and midwifery personnel constitute the largest component of the health workforce and deliver, or supervise, most of the health services provided worldwide' (WHO 2000). Increasingly and in many parts of the world nurses provide the first and possibly only point of contact with the health service. Among the poor and in remote rural areas, nurses are particularly well-placed to meet the everyday needs of patients referring them to a doctor only if the need arises (Smith 1995). The International Council of Nurses (2009a, 2009b) has made clear that it regards gender as an important issue for nursing care. Unless nurses understand the ways in which gender is culturally and socially constructed they will not appreciate the implications of health policies, legislation and planning for women and men. In effect this means that inequalities will be perpetuated, particularly in situations in which power and decision making are concentrated in one gender. Their close involvement with patients means that nurses are in a position to ensure that women's and men's needs are articulated (ICN 2009a).

However, making these needs heard is no simple task. This collection begins with a research paper that demonstrates how complex inequalities can be especially for those living on the margins of society. Washington, Moxley, Garriott, and Crystal (2009) present a compelling case for a multifaceted approach to helping older black African American women to gain permanent housing. Debt, poor health, poverty, bereavement, lack of education and housing conspire to render the women powerless. Tackling one issue will not resolve an individual's situation. This paper shows how, with careful planning, women can become empowered again and start to regain control over their own lives. The methodology used is particularly important in this, reflecting a dialogic approach in which academics have worked with the women, researching and building a new venture with them rather than the traditional approach of a project about them.

The second paper in this collection also concerns another group that can also be socially marginalised especially in countries in which homosexuality is illegal. Stephen Neville and Jeffrey Adams' (2009) review highlights the key points in decision making about whether or not to use a condom during intercourse. Men who have sex with other men are very diverse. Some are homosexual and have regular partners whereas others seek out multiple partners, work as prostitutes or engage in casual sex. Heterosexual men, with female partners may also engage in sex with other men. Social isolation and fear may lead men to take risks such as having unprotected sex. The implications for nurses are quite clear. Making assumptions about people can prevent nurses from accurately identifying a man's health problems and the possible causes. The stigma that is still attached to being gay, even in parts of liberal societies, means that coming out is not easy; moreover, coming out is never a single event as the man has to decide whether to risk disclosure to different people in diverse settings (Cant & Taket 2006). Thus, for gay men, coming out is a series of events in time and place. Nurses need to be sensitive to this and judge accurately whether it is appropriate to broach the possibility of sex with other men and the circumstances involved in order to provide appropriate healthcare.

The next two papers address the issue of gender and nursing from the perspectives of nurses themselves. Like their patients, nurses are gendered beings and, therefore, as likely as their patients to experience the effects of gender-based inequalities. Worldwide, figures indicate that most nurses are female and the vulnerability of women to discrimination and disadvantage is also well established. Whilst progress has been made, equal pay, women's rights, and opportunities are still key issues even in developed, liberal societies. Women are still routinely paid less than men for the same work. Gender segregation limits women's choice of occupation or may prevent it altogether. Career advancement is still restricted with far fewer women than men holding senior positions in government, business and industry (ICN 2009b). In the third research paper, Pannowitz, Glass, and Davis (2009) reveal the various subtle ways in which discrimination operates at senior levels in an organisation, so subtle in fact that some of the time, the women were not even aware of it. Those who were aware did not confront their oppressors but engaged in a form of game playing, preferring instead to work around unhelpful individuals or practices. In fairness, they probably had little option but this paper also raises questions about whether the game playing between doctors and nurses described by Stein (1967) and Stein, Watts, and Howell (1990) has now taken a new direction as nurses have to interact with managers and chief executives. However, it is also possible that some women really do believe that they no longer need to worry about gender inequalities, that they now live in some post-feminist arcadia; that feminism no longer matters. It is part of the past, a time of 'po-faced earnestness ... a movement where all too often humour has been missing (and) you have to subscribe to a specific set of views' (Levenson 2009). As Pannowitz et al. (2009) show, such naivety reflects a woeful ignorance of the realities of what is really happening around them.

In this context Brian Brown (2009) challenges the perception that, as the majority of nurses are female, male nurses are disadvantaged in the same way that women are disadvantaged in other occupations. In Brown's (2009) view, the discourse about men and masculinity and their struggles as a minority in nursing, infantilises men and conveniently ignores the ways in which they operate as a group. There may be fewer men in nursing but their career trajectories are steep and rapid as they ascend through the ranks to occupy the more senior and better paid positions. What we need, Brown (2009) argues is not poor me accounts about how men suffer, but an adult discourse about men and women in the nursing workplace.

The final paper in this collection focuses on Australian Aboriginal people. Catrina Felton- Busch (2009) explains the importance of giving birth on country, a tradition that binds the newborn with the ancestral land. This tradition carries ancient rights and responsibilities of immense significance that can only be acquired through birth in a particular place. Birth elsewhere may confer clan membership but the absence of the traditional tie to the land is missing; birth off country is just not the same. The idea of such ties is not unusual. Every society sets parameters that enable individual members to define the boundaries of the self. These extend beyond the body through a series of symbolic skins (Helman 2007): clothing, adornments, housing, localities, membership of a social or kinship group. These symbolic skins form a boundary between the self and others, between those we define as one of us and those who are different. Symbolic skins can extend a considerable distance, even to 'the borders of (the person's) nation state (whose symbolic orifices are airports, harbours and border posts)' (Helman 2007, p.24).

The importance of symbolic skins has, historically, been ignored in maternity care. This is not a situation peculiar to Australia; decisions about how and when women should give birth have been, and continue to be, formulated by those least likely to become pregnant. Felton Busch's (2009) description of having to go off country to give birth reflects, to some extent, the patriarchal idea that men and professionals know best. However, in Australia there do seem to be additional considerations. The latest report on Aboriginal well being shows a widening gap between Aboriginal and other Australians. Mortality rates for Aboriginal 'infants and young children remain two to three times as high as those for all infants and young children' (SCRGSP 2009, p.3). Child abuse and neglect among Aboriginals is up to six times higher than among other Australians. The imprisonment of Aboriginal women has increased by 46% since the beginning of the century. Low educational attainment and high levels of unemployment complete the picture of severe disadvantage among the 517,000 Aboriginal people (SCRGSP, 2009). However, there are signs of hope. The report identifies key messages but, most importantly, lists developments that actually seem to work. For example, 'the Healthy Heart Cardiac Rehabilitation Program provided by the Wuchopperen Health Service, in partnership with the Cairns Base Hospital, has significantly improved Indigenous participation in cardiac rehabilitation programs' (SCRGSP 2009, p.44). In addition, 'the Aboriginal Burns Program (SA) was developed in response to the overrepresentation of Aboriginal people in the South Australian Burns Service. It includes prevention and pre-hospital care through to acute care and rehabilitation' (SCRGSP 2009, p.46). This is important information for service planners and nurses alike, facilitating the sharing of good practice to bring about improvements in Aboriginal people's health.

The collection is brought to a close by Kim Walker (2009), the co-editor of this collection. We hope that readers will find these papers helpful and thought provoking. Most importantly, we hope that nurses will consider taking up the ideas presented here in their continued efforts to provide healthcare for men and women.

View references

Navigate: Archives | Contents | Top of page

Search

Translate

Related Publications from eContent Management