learning about gender Learning about gender on campus: an analysis of the hidden curriculum for medical students Ling-Fang Cheng & Hsing-Chen Yang
CONTEXT Gender sensitivity is a crucial factor in the provision of quality health care. This paper explores acquired gendered values and attitudes among medical students through an analysis of the hidden curriculum that exists within formal medical classes and informal learning. METHODS Discourse analysis was adopted as the research method. Data were collected from the Bulletin Board System (BBS), which represented an essential communication platform among students in Taiwan before the era of Facebook. The study examined 197 gender-related postings on the BBS boards of nine of 11 universities with a medical department in Taiwan, over a period of 10 years from 2000 to 2010. RESULTS The five distinctive characteristics of the hidden curriculum were as follows: (i) gendered stereotypes of physiological knowledge; (ii) biased treatment of women; (iii) stereotyped gender-based division of labour; (iv) sexual harassment and a hostile environment, and (v) ridiculing of lesbian, gay, bisexual and transgender (LGBT) people. Both teachers
and students co-produced a heterosexual masculine culture and sexism, including ‘benevolent sexism’ and ‘hostile sexism’. As a result, the self-esteem and learning opportunities of female and LGBT students have been eroded. CONCLUSIONS The paper explores gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms. Both teachers and students, whether through formal medical classes or informal extracurricular interactive activities, are noted to contribute to the consolidation of such norms. The study tentatively suggests three strategies for integrating gender into medical education: (i) by separating physiological knowledge from gender stereotyping in teaching; (ii) by highlighting the importance of gender sensitivity in the language used within and outside the classroom by teachers and students, and (iii) by broadening the horizons of both teachers and students by recounting examples of the lived experiences of those who have been excluded and discriminated against, particularly members of LGBT and other minorities.
Medical Education 2015: 49: 321–331 doi: 10.1111/medu.12628 Discuss ideas arising from the article at www.mededuc.com discuss.
Graduate Institute of Gender Studies, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence: Hsing-Chen Yang, Graduate Institute of Gender Studies, Kaohsiung Medical University, 100 Shichuan 1st Road, San-Min District, Kaohsiung 807, Taiwan. Tel: 00 886 7 312 1101; E-mail: [email protected]
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L-F Cheng & H-C Yang failed to address issues of gender equity and some were even deemed to reproduce gender stereotypes.10
INTRODUCTION
Since the adoption of gender mainstreaming as policy by the United Nations Fourth World Conference on Women in 1995, some leading universities in Europe, North America and Australia have actively sought to integrate gender into medical education.1–5 Many research papers on medical education have pointed to the importance of including gender perspectives to promoting the quality of health care.1 Physicians who have acquired enough knowledge and understanding of gender differences in symptoms and risk factors in various diseases, and adapted their diagnoses and treatments accordingly, are shown to be able to more effectively treat their patients.1,6,7 These papers further point out that in the majority of biomedical textbooks and education programmes, gender issues are still perceived as representing ‘women’s problems’: differences of sex and gender, as well as in physiological symptoms, are often simplified without taking into account their complex social-cultural context; knowledge of health and medicine still appears to be ‘male-centred’ to a great extent, with the male physiology regarded as the ‘standard’ norm, and gender-associated differences are often downplayed or ignored in diagnosis.1,3–5 In Taiwan, the practice of biomedicine has for many years represented one of the most privileged professions and is in part a legacy of Japanese colonial rule, which ended in 1945. Women have been admitted into the profession only since the mid1950s, and despite recent changes in gender equity, male students still predominate. For instance, the profile of the student body shifted from 77.6% male and 22.4% female in 1997 to 67.4% male and 32.6% female in 2012.8 The professional community likewise remains male-dominated; the evidence points to the ongoing permeation of the profession by a masculine culture that sets the norm and receives little challenge.9 The unequal gender ratio and the perceived dominance of masculine culture in the medical profession and medical education were the targets of reform when the Gender Equity Education Act was promulgated in 2004. The Act requires that universities set up courses related to gender equality. According to a study on gender education curricula developed in Taiwanese universities from 2001 to 2010, although the quantity of courses had grown, they remained obviously inadequate; many courses claimed to be gender- or female-related, but in fact
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In 2006, the Medical Education Committee of the Ministry of Education commenced a series of programmes intended to integrate the concept of gender equality into medical education. Its approach was to conduct annual seminars targeting teaching staff, aiming to raise their gender awareness and gradually to infuse gender into the formal curriculum, thus initiating a ‘trickle-down’ effect on the outlook of students.9 From this it can be seen that medical education practitioners had taken on board the importance of cultivating awareness of gender equality and its values on campus. The evidence so far raises doubt as to the effectiveness of this top-down approach11 and suggests that a thorough understanding of how students learn gender values through daily interactions on campus may be a vital part of the reform of medical education.3– 5,9 To this end, we sought to investigate whether and how any hidden curricula may be at play. In their proposal for integrating gender into medical education, Yang and Cheng12 draw our attention to the effective power of such a hidden curriculum in medical training. How can such a hidden curriculum be understood in the context of medical education? There are two closely related interpretations of the mechanisms of such a curriculum. One implies a general influence on student development through the cultivation of values and attitudes that are derived from the material and cultural environments, such as buildings, equipment and campus rituals, as well as from personal relationships, such as in teacher–student relationships and interactions among students.13 To describe the other interpretation, Zelek et al.14 draw our attention to the content, language and process of formal curricula: ‘What is the “hidden curriculum”? When examples about women are appended in parentheses, are always presented after those about men or are limited to reproductive issues?’ Initiatives such as the Women’s Health Interschool Curriculum Committee of Ontario in Canada may be one example of the counter-approach to such curricula. Zelek et al.14 emphasise the significance of diversity of presentation and the usage of non-gender-biased language in communication with statements such as: ‘Female and male patients should be represented in equal numbers in examples, problems and case studies’ and ‘Terms that
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Learning about gender on campus trivialise or stereotype women should be eliminated.’ Both views inform us that the hidden curriculum exists within and outwith formal medical classes; it is intertwined with formal teaching and informal learning. What students acquire outside classes will be brought into their formal education; equally, if the medical education integrates gender perspectives, then students will carry these into their daily and professional practice in the future. Given the potential influence on students of aspects within the hidden curriculum, we wished to explore the gendered world of medical students by analysing the language they use in social communication on campus.15 The presentation of this language can provide a glimpse of the sociocultural context in which the speakers are located, and the gender values and attitudes they possess and express. Theoretical framework We adopted two related theoretical frameworks for analysing the presentation of language. One of these, coined by R W Connell,16 refers to hegemonic masculinity and subordinate masculinity. Hegemonic masculinity is used here to indicate a pattern of practice that sustains men’s dominance over women, masculinity over femininity, and heterosexuality over homosexuality. According to this approach, Western society privileges a number of characteristics, such as violence, aggression, courage, toughness, risk-taking, adventure, emotional restraint, competitiveness and success. Boys and men internalise these characteristics in daily interactions with family members and at school and in the workplace; these masculine characteristics are also reinforced via cultural, economic and legal arrangements. Hegemonic masculinity justifies the dominance of heterosexual men and the subordination of homosexual and effeminate men who exhibit physical weakness or emotional expressiveness. Homosexual and effeminate boys and men often run the risk of being socially, culturally, legally and economically excluded and discriminated against. A key feature of hegemonic masculinity, according to Connell,16 is a brotherly complicity to privileged masculine characteristics, for which there appears to be much evidence among the university students discussed in this paper. The other framework refers to the ambivalent sexism theory suggested by Glick and Fiske,17,18 which
appears to work well in attempts to explain the daily interaction of medical students on campus. These authors point out that both ‘benevolent sexism’ and ‘hostile sexism’ derive from the power structure of patriarchy, which assigns superiority and inferiority to males and females, respectively. ‘Benevolent sexism’ is here represented in the form of protection by the father and brother, idealised female images, and the stereotyping of physical weakness and emotional expressiveness in women and LGBT (lesbian, gay, bisexual and transsexual) people, whereas ‘hostile sexism’ emphasises the negative values and images of femininity, and practises surveillance and control, and exclusion with hostility. The present study focuses on the gender values and attitudes that medical students acquire from such hidden curricula, and endeavours to establish what kind of information they convey. The study aims to point out areas which formal and informal medical education might seek to target and strengthen in future reform. We indicate how these may provide starting points for the integration of gender in medical education from the bottom up, and thus assist education reformers in their efforts to locate and resolve such problems.
METHODS
This study was conducted across nine of the 11 universities in Taiwan that maintain a medical department. The data were collected from all Bulletin Board System (BBS) forums run by medical departments. The BBS was an interactive digital communications system, popular among students from the mid-1990s to 2010, when Facebook arrived in Taiwan, which functioned mainly as a tool through which community members could circulate information about activities, make comments on social and sporting events, express concern over certain issues, and relax by chatting and joking. Each board included a student elected as administrator; this person was responsible for controlling the discussion board content and entitled to mark or delete posts. The BBS system would also automatically delete posts when the board exceeded its storage limit, and would retain only the marked items.19 The postings collected were sourced from openaccess web-based archives, which include 19 666 marked posts not deleted by either the administrator or the system, of which around 1% (i.e. 197 items posted during 2000–2010) were found to be gender-related. Furthermore, 94% of these were posted by male students.
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L-F Cheng & H-C Yang We found Internet forums were ideal for understanding the gender-related values and attitudes of the posters, as BBS users often wrote messages no longer than one or two lines of text under no pressure or in a light-hearted and casual style; therefore the discourse of comments and jokes is likely to reflect their undisguised views and values. Discourse analysis was used to analyse the data in a process during which we noted the paradoxical discourse of both the use of language and the maintaining of silence. As Cammack and Phillips15 have noted, an individual’s comments or jokes reflect submission to certain dominant discourses which shape self-understanding and reconfirm certain social-cultural norms. We began by sorting the data according to the theoretical concepts. The first step was to sort the data according to the following concepts: display of masculine power (20.7%); display of feminine power (0%); unequal treatment of women (33.0%); women’s protest (1.5%); equal treatment of women (0%); attitudes towards LGBT people (16.5%); LGBT protest (0%); benevolent sexism (14.3%); hostile sexism (9.0%), and other (5.0%). As the year 2004 saw the promulgation of the Gender Equity Education Act in Taiwan, in order to grasp its impact or the change caused, each category was subdivided into two periods: ‘before 2004’ (32% of total data), and ‘from 2004’ (68% of total data). The second step was to make cross-comparisons of the data and select posts that were rich in social meanings and representative of issues. The final step was to focus on five mutually exclusive categories to yield results. The postings discussed in each category represented typical gender-related values and attitudes mostly shared among male students and teachers. For the sake of research ethics, sources were marked with codes in order to allow us to track the medical departments for discussion; thus a quotation marked as ‘2009/A/M’ indicated the post had been written in 2009 by a male student from university A. Some quotations were edited, but this was done in a way that ensured their original meaning was unchanged. Last but not least, the validity of the study should be addressed.20 These 197 postings, left on the BBS for open access, were selected either by the administrators or randomly by the system; it is not possible to establish in which social context some posts were deleted and some kept. However, we argue that the validity of data interpretation can be ensured in the following ways. Firstly, the postings we identify as having distinctive characteristics and rich social
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meanings are mostly controversial or more popular than average. Secondly, the gender issues raised in the data must have some public significance rather than just personal importance. Thirdly, consultations with female medical students with feminist awareness about ‘shared lecture notes’ and general interactions on the BBS confirmed our findings. Fourthly, the first author has been actively engaged in organising annual seminars on gender equity for medical teaching staff for the Ministry of Education and edited a special issue of a journal on integrating gender issues into medical education in 2008.21 Finally, both researchers have been teaching and researching in gender studies for over a decade, and educators for medical professionals since 2006; they are confident of detecting the exercise of masculine power and practice of sexism as illustrated in the postings.
RESULTS
We have noted that sexism is mediated through the use of the language of gender discrimination and sexual harassment; we shall reveal that sexual prejudice and hostility towards sexual minorities are repeated in various forms in the writings on the BBS. The following are the most distinctive characteristics shared by medical students and sometimes teachers. Gender stereotypes of physiological knowledge Physiological differences between males and females have long been used as ‘evidence’ to justify the unequal treatment of men and women in society; in our project, we found a similar pattern in wisecracking on the BBS: Let me tell you all, the easiest way to remember the positions of the aorta and the vena cava is to follow the rules of Chinese palm reading which take [the] male left hand and [the] female right hand. The aorta is an active one so is located at the left to spine, vena cava is a quiet one so at the right. Why is the liver on the right of the spine? Because it produces the extra blood women need for their monthly periods. Why are testicles located at the lowest part of [the] male body? Because men have to kneel down to make a wedding proposal. (2003/D/M) Such puerile connections between gender and body function may be regarded as harmless at first sight,
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Learning about gender on campus yet they may also be perceived as serving to perpetuate and reinforce gender stereotypes. Jokes and wisecracks focusing on body parts were also made by teaching staff. For example, one male student refers to a lecture in which he quotes the teacher as saying: These are two large tumour cells growing on either side of the artery; they are just like the testicles on all you male students. This particular student adds a comment to this:
the structures of the heart and lungs, he would not publicly disgrace them. However, he really gave me a hard time when I failed to do so; probably it meant I was the tough guy, the king of the manly guys, so I deserved it? (2006/B/M) A teacher’s differential treatment of female and male students in class can be understood as a message confirming a widely spread gender attitude: that men should be taken more seriously than women. Male students also teach one another how to become a man with authority:
Well, mine are actually a lot bigger! (2005/H/M) Same-sex anal intercourse also appears as a frequent source of classroom amusement. One pathology professor is quoted as saying that a high proportion of tuberculosis patients are unaware that they are human immunodeficiency virus (HIV)-positive and that medical personnel might waste a lot of time carrying out all kinds of tests before discovering a patient’s HIV status. A student who found this comment particularly amusing pasted it on the BBS and wrote: But how can we be expected to carry out a rectal examination each time a TB patient comes to seek our help! (2008/F/M) Biased treatment of women Female students constitute one-third of medical students. In this minority position, they appeared to be treated in ways seemingly contradictory but consistent with patriarchal order. In other words, they were constructed as being helpless, needing to be tamed and as sexual objects. Female students tend to be taken under the wing of male contemporaries, implying that they are weak and incapable, which is in keeping with a traditional image of femininity. Messages to this effect appear repeatedly in BBS discussions:
If your girl asks you to go to a movie while you are playing basketball, just tell her: “Shut up, don’t interrupt while a man is playing sport.” I bet she will admire you even more. (2010/E/M) This is regarded as an instance of ‘taming’ a woman and learning to be a ‘proper’ man on campus. Cracking jokes with sexual innuendo was found to be a common practice in social activities as well as in BBS messages, and appeared often to be regarded as harmless fun by the majority of male students: Female students whose tits are too small to show any cleavage would definitely have difficulties forming alliances with male students. (2006/G/ M) Similar postings present themselves as expressions of humour: Male students in the medical department are handsome and talented; the females are famed for their huge tits. (2004/H/M) Female students in the nursing department have hot and spicy figures and great looks; if anyone wants a date, leave me a message. (2002/I/M) Stereotyped gender division of labour
Please demonstrate your masculine power; if a female classmate is incapable of running the computer program, you should give her a hand. (2007/A/M) Another comment conveys a similar message: Teacher W often has a soft eye for women students; if they failed to give the correct answers to
We found that a stereotyped gender division of labour predominated in many activities as recorded on the BBS. Here are five examples for discussion. The first posting, referring to requirements for a ceremony to acknowledge body donors, states: Two flower presenters are called for from each class. These should be one male and one female,
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learning about gender Learning about gender on campus: an analysis of the hidden curriculum for medical students Ling-Fang Cheng & Hsing-Chen Yang
CONTEXT Gender sensitivity is a crucial factor in the provision of quality health care. This paper explores acquired gendered values and attitudes among medical students through an analysis of the hidden curriculum that exists within formal medical classes and informal learning. METHODS Discourse analysis was adopted as the research method. Data were collected from the Bulletin Board System (BBS), which represented an essential communication platform among students in Taiwan before the era of Facebook. The study examined 197 gender-related postings on the BBS boards of nine of 11 universities with a medical department in Taiwan, over a period of 10 years from 2000 to 2010. RESULTS The five distinctive characteristics of the hidden curriculum were as follows: (i) gendered stereotypes of physiological knowledge; (ii) biased treatment of women; (iii) stereotyped gender-based division of labour; (iv) sexual harassment and a hostile environment, and (v) ridiculing of lesbian, gay, bisexual and transgender (LGBT) people. Both teachers
and students co-produced a heterosexual masculine culture and sexism, including ‘benevolent sexism’ and ‘hostile sexism’. As a result, the self-esteem and learning opportunities of female and LGBT students have been eroded. CONCLUSIONS The paper explores gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms. Both teachers and students, whether through formal medical classes or informal extracurricular interactive activities, are noted to contribute to the consolidation of such norms. The study tentatively suggests three strategies for integrating gender into medical education: (i) by separating physiological knowledge from gender stereotyping in teaching; (ii) by highlighting the importance of gender sensitivity in the language used within and outside the classroom by teachers and students, and (iii) by broadening the horizons of both teachers and students by recounting examples of the lived experiences of those who have been excluded and discriminated against, particularly members of LGBT and other minorities.
Medical Education 2015: 49: 321–331 doi: 10.1111/medu.12628 Discuss ideas arising from the article at www.mededuc.com discuss.
Graduate Institute of Gender Studies, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence: Hsing-Chen Yang, Graduate Institute of Gender Studies, Kaohsiung Medical University, 100 Shichuan 1st Road, San-Min District, Kaohsiung 807, Taiwan. Tel: 00 886 7 312 1101; E-mail: [email protected]
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Learning about gender on campus intent was calculated to disturb and punish. One female student posted on the evening before an examination: What a swine! He stole the identities of three different classmates and made postings declaring his love for me, it really bothered me. You may think you are under a lot of pressure from your studies, and find this an amusing diversion, but you made me fret all night, and I was unable to prepare for my calculus exam. (2007/A/F) Ridiculing LGBT Notices ridiculing LGBT people and issues appeared many times on the BBS. Expressions such as ‘playing gay’ and ‘gender disorder’ are often jokingly exchanged among students. For instance, a birthday greeting might be: Hope you get rid of your sissy style next year. (2008/C/M) Some female students share such sentiments but express themselves in a milder manner: I hear that those departing the women’s basketball team all become stars on the softball team, so why don’t you try your luck with the softball team? (2009/B/F) But. . . I hear there are lesbians on that team, so better to go for table tennis. (2009/B/F) This might be classified as soft homophobia conveying a sense of refusal. Students often discuss films on BBS boards. Our data included posts made by students after watching a Spanish film entitled Bear Cub, which was shown on campus and is about a caring relationship between an HIV-positive gay dentist and his nephew: Those in [the] dentistry department should be alert! Fortunately, we are in [the] medical department. (2007/F/M) How come I get the impression the film is about sexual dysfunction? Am I mistaken? (2007/F/M) What a bad influence on the nephew! (2007/F/M) Another discussion about the film Boys Don’t Cry also appears to illustrate a general lack of any sense of
the experience of oppression of LGBT medical students. This film is about a transgender person who is beaten, raped and murdered by male acquaintances after they discover he is physically female. One female student posted: . . .one doesn’t have to accept the transgender, but please do not harm them. (2010/F/F) This elicited the retort: She was killed not for being transgender; it was due to the ways she chased the woman she loved. (2010/F/M) The latter comment suggests an individualistic approach towards such tragedy, which does not acknowledge the social hostility that is endured by homosexual and transgender people, and accuses the transgender character of improper behaviour. One post condemned a teacher’s explicit expression of his moral views in class: No sex before marriage? Homosexuals cause social chaos? Teacher, how can you come up with such crap? (2008/G/M) The fact that some teachers felt no inhibition in openly expressing hostility towards LGBT groups may be seen as an alarming phenomenon for medical education reformers.
DISCUSSION
In the context of a hidden curriculum, the sexually discriminatory language and its gender scripts on the BBS provide a learning platform for reconfirming patriarchal values. Using this approach, we can identify two distinct characteristics in terms of learning gender on campus. Heterosexual masculinity as the culture Western readers might find shocking the open use of degrading words and jokes about women and LGBT groups on the BBS. However, the absence of any inhibition in expressing sexually discriminatory attitudes and words on the part of male students reflects the culture of hegemonic masculinity in the community of medical students in Taiwan, and the resulting laughter and appreciation of such jokes also foster an atmosphere that privileges malecentred and male-defined values.16,22
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L-F Cheng & H-C Yang Physiological knowledge is supposed to be ‘neutral’ and not to hold any gendered association. However, as Emily Martin’s23 famous critique points out, the interaction between the egg and millions of sperm has been constructed by scientists as a romance based on stereotypical male and female roles. As we have noted, the acts of making puerile connections between female menstruation and the fact that the liver is located to the right of the spine, between the location of testicles and the fact that a man may kneel to make a marriage proposal, as well as between male sexual prowess and two large tumour cells located on either side of an artery are also based on stereotypical male and female roles. Even the pathology professor makes a scientifically unsound connection between HIV positivity and rectal examination. There is a long tradition of wisecracking in the medical community in Taiwan in which physiological knowledge is often presented in the form of gendered stereotyping, and it is this social context that gives rise to the postings on the BBS. The pleasure gained from commenting on women’s breasts and figures, arguing for adding a picture of a nude woman in the shared lecture notes and sharing the news about dating girls with ‘spicy figures and great looks’ can be seen as a means of bonding among the ‘heterosexual brotherhood’. Whether they are collectively endorsing an unmarried teacher’s desire for wealth and a wife, or individually learning to show male authority over a girlfriend, these are ways by which men can reconfirm their masculine subjectivities, reinforce patriarchal control over women and practise surveillance over one another.24–27 One area of comment that arises frequently concerns male boasting about sexual prowess. This tends to be humorous and yet boastful, such as when a male student claims to have giant testicles, echoing the masculine sentiments expressed by the teacher in the class. Competition among males, especially in terms of sexual prowess, is an important aspect of masculine culture. Had anyone from the minority group of female students protested against such jokes, she would probably have faced tremendous pressure and been labelled as ‘unfriendly and fussing over nothing’. The cautious and hesitant image of female students we receive can be explained by the isolation and exclusion they experience in such a male-dominated learning environment. Female students showed themselves to be uncomfortable in joining in such discussions and chose instead to keep a low profile or to play only a marginal role in interaction on the BBS.
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The devaluation of subordinate masculinity on the BBS often occurred in the form of jovial banter. The birthday greeting ‘. . .hope you get rid of your sissy style next year. . .’ conveys the message that a ‘sissy style’ does not fit in and may lead to exclusion by the male community. The discussion of the film Bear Cub again reveals negative views about homosexual and HIV-positive people, who are treated as laughing stocks not only among medical students. The joke used by the class teacher who suggested that rectal examination could be used to determine HIV-positivity in homosexual men is a typical one. It suggests some real inner fear of catching acquired immune deficiency syndrome (AIDS) in medical practice, as well as an unspoken yet pervasive homophobia. Sexism caused by stereotyping and ignorance The examples illustrated herein provide ample evidence that stereotyped gender images are deeply ingrained. In their postings, students associate strength and power with the male, and inactivity and passivity with the female. For example, the ceremony held to express gratitude to body donors is regarded as an emotional occasion and thus female students are expected to present the flowers. Elsewhere, it seems to be perceived as caring to offer to help a female student to run a computer program, or to assign to women students only the ‘feminine’ jobs such as reception duty, cooking, secretarial tasks and cheerleading, while male students take on the ‘hard and heavy’ jobs. Paternalistic protection is also demonstrated in differential treatment in teaching. Teachers’ protective attitudes effectively imply that they do not expect high levels of academic achievement from women students and hence there is no need to push them. This undemanding attitude towards women students in their academic pursuits signals their exclusion from the inheritance of knowledge, whereas placing high expectations on male students conveys the message that they are seen by teachers as their potential successors. These attitudes can be appropriately described as representative of benevolent sexism towards female students.17,18 Benevolent sexism is often confused with well-meaning acts of protecting and caring. It is in reality an exercise of paternalistic power over a minority and marginalised group. In the long run it exerts at least two kinds of invisible impact. One is to assign the decorative, domesticated and protected roles to women students, trap them in an invisible cage of
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Learning about gender on campus self-devaluation and self-constraint and exclude them from taking on challenging roles; the other is to reinforce traditional gendered roles in the selfidentity and projected identity of male and female students, which they will carry into their professional workplaces and future family lives. Such harm is beyond measurement and should not be the purpose of medical education.24 The postings on the BBS give an impression that female students were subject to only benevolent sexism, whereas LGBT students experienced hostile sexism.17,18 Overall LGBT individuals and issues were the objects of much teasing and bantering on the BBS, on which the homophobia expressed is even worse than the misogyny. We believe this homophobia derives from stereotyping and ignorance, as well as the practice of control and surveillance in a culture of hegemonic masculinity, which is very heterosexual by nature.16 The BBS discussion of the film Boys Don’t Cry indicates that ignorance of the social, cultural and even economic predicaments of LGBT groups is prevalent among medical students. It is surprising to see that LGBT status retains a negative image as representing a ‘disorder’ or ‘dysfunction’ that should be corrected or cured, even as late as 2007, given that such categories had been removed from the Diagnostic and Statistical Manual of Mental Disorders (DSMII) as early as 1973. Moreover, comments such as ‘homosexuals cause social chaos’, expressed in a class by a teacher, may inflict harm on invisible LGBT students who remain silent in the classroom. If no-one dares to stand up against such homophobia, it is seen to be acceptable. A study on homophobia among medical students in Hong Kong echoed the situation in Taiwan, indicating the importance of developing an LGBT-friendly curriculum.28 Hostile sexism is demonstrated not only towards LGBT groups, but also towards women on some occasions. As mentioned before, the display of a nude female in the shared lecture notes and the creation of an atmosphere of constraint have served to prevent women students from raising forceful protests. These are some of the effects of a misogyny that is deeply embedded in a patriarchal culture and reduces women to nothing more than objects of male sexual desire. Another case of relevance involves the hoax love messages sent to a female student to cause emotional disturbance before an examination. This would no doubt be regarded as an act of sexual harassment. This behaviour is likely to have derived from a hostile atmosphere that has existed for some time, rather than representing a unique incident of mischievous misconduct.
Pascarella and her colleagues, having examined the state of play on American campuses, suggested that the longstanding ‘chilly climate’ would have serious negative impacts on the self-esteem and academic development of female students, whereas a friendly and supportive campus network would enable the academic performance of female students to flourish.29 We would also apply this to students in LGBT groups. Our study shows that both heterosexual masculinity as representative of the dominant culture and sexism caused by stereotyping and ignorance are two distinct characteristics of the hidden curriculum; they are in fact co-produced by teachers and students through interaction within and outwith formal medical education, as well as in formal teaching and informal learning.
CONCLUSIONS
Following the argument promulgated by Aikman et al.30 that ‘education quality demands an analysis of gender dynamics in the wider social context of the lives of boys and girls’, the present paper has explored the role of gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms that reflect mainstream gendered relations in Taiwan during 2000–2010. It is also noted that both teachers and students, whether they have formal medical classes or informal extracurricular interactive activities, contribute to the consolidation of such norms. The analysis of BBS messages has thrown new light on the dark side of this gendered subculture and sends out alarming signals to educators. It brings to our attention that it is important to break the silence of sexual minorities and marginalised people and to make the invisible become visible. One might wonder how heterosexual masculinity and stereotyped sexism prevalent in the subculture of medical students may affect women physicians in the workplace and the quality of the care delivered to diverse patients. There is no direct evidence to prove the influence of the hidden curriculum on these matters; however, two examples may provide a glimpse. Firstly, according to a study on gender differences in specialty selection among novice physicians in 2007 in Taiwan,31 males tended to select internal medicine, surgery and emergency medicine, the former requiring doctors to spend more time on reading and solving complicated cases, and the latter demanding physical strength and risk-taking; these specialties are closely associated with masculinity. The top four
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L-F Cheng & H-C Yang favourite specialties of women physicians were paediatrics, family medicine, obstetrics and gynaecology, and psychiatry,31 all of which are closely related to family care. The selection of specialties in novice physicians can be perceived as following the traditional gender division of labour. This is by no means true only of Taiwan. Two studies on the impacts of the hidden curriculum on gendered career choice showed similar results in Australia and Canada. Female medical students were found to prefer ‘female-friendly’ career choices, viewed motherhood as a negative impact on their medical careers and expected to put their families before their careers.32,33 Secondly, as mentioned previously, medical teachers and students tend to associate AIDS with homosexual men and are worried about contracting HIV in medical practice. According to a news story in June 2014, a hospital in southern Taiwan was fined because a homosexual patient who had requested surgery was given an HIV blood test without his consent.34 What are the recommendations for change? The present findings give rise to three tentative directions for further education reform. Firstly, physiological knowledge should be separated from stereotyped gender association in teaching. Goodquality teaching requires illustrations to be interesting and humorous, neither of which should be fostered at the expense of women by using them as sex objects or LGBT groups by making them laughing stocks. The cases discussed in this study can serve as examples for lively discussion and selfreflection in class. Secondly, it is essential to promote gender sensitivity in the use of language in class by teachers and in extracurricular activities by students. As Zelek et al.14 point out, ‘. . .language should be examined to determine whether the words used to convey information subtly promote and maintain stereotypes about either sex or are emancipatory.’ The postings on the BBS can be elaborated to form case studies and teaching materials for use in formal medical classes. It is expected that through conversation, discussion, consciousness-raising and self-reflection, both teachers and students can gradually come to realise how heterosexual masculinity works in practice and how sexism can inflict harm on many silent minorities. Thirdly, the ignorance about LGBT issues as disclosed in the above analyses can be gradually diminished by telling the stories of how these minorities have faced exclusion and discrimination. The close examination of personal experience has been shown to be vital to transforming individual awareness.24 Recounting of the lived experiences of
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these invisible minorities can slowly erode the bias and expand the horizon of medical students, and, it is hoped, contribute towards their becoming good doctors. A longitudinal study of 13 881 college students in the USA conveyed an optimistic message indicating that individuals can become more accepting of LGBT relationships after 4 years of college life, thereby proving that students have the capacity to transform prejudice by broadening their life experience, including by learning gender equity on campus.35 As BBS postings can be deleted by the board administrator or randomly by the system, it is impossible to track any valid changes in the last 10 years. However, despite this limitation, awareness of gender equity in Taiwanese society has certainly progressed since the implementation of the Gender Equity Education Act in 2004. If the suggested directions for education reform and the promotion of a gender-sensitive medical pedagogy come to be adopted and practised in Taiwan, the prevalences of both benevolent sexism and hostile sexism, as well as the domination of heterosexual masculinity, are likely to diminish in medical subculture. Medical education reform must focus not only on the integration of gender perspectives into the formal biomedical teaching programme, but also on eradicating the sexist and homophobic hidden curriculum in which the dominance of hegemonic masculinity and sexism are at play. In other words, teaching staff should take gender equity training seriously, and medical students should be required to take gender equity-related courses. Both strategies may reinforce the cultivation of gender sensitivity and diminish the subculture of misogyny and homophobia.
Contributors: L-FC contributed to the study conception and design, and the acquisition, analysis and interpretation of data. H-CY contributed to the study conception and design, and the analysis and interpretation of data. Both authors contributed to the drafting of the paper. L-FC conducted its critical revision. Both authors approved the final manuscript for publication. Acknowledgements: this work is supported by J. Y. Gu and T. H. Wang by their assistance with data collection. Special thanks to T.H. Wang for assisting draft preparation. Thanks to Paul Crook, Xue Feng and Jocelyn Watson for proofreading, your invaluable assistance make the texts shine. Funding: Taiwan National Science Council No. NSC992511-S-037-002. Conflicts of interest: None. Ethical approval: Not applicable.
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Learning about gender on campus
REFERENCES 1 Kuhlmann E, Annandale E, eds. The Palgrave Handbook of Gender and Healthcare. London: Palgrave Macmillan Press 2010. 2 Lagro-Janssen T. Gender and sex: issues in medical education. Med Educ 2010;29:48–53. 3 Verdonk P, Mans LJL, Lagro-Janssen ALM. Integrating gender into a basic medical curriculum. Med Educ 2005;39:1118–25. 4 Verdonk P. Medical students’ gender awareness. Sex Roles 2008;58:222–34. 5 Verdonk P, Benschop Y, de Haes H, Mans L, LagroJanssen T. ‘Should you turn this into a complete gender matter?’ Gender mainstreaming in medical education. Gend Educ 2009;21:703–9. 6 Lagro-Janssen T. Sex, gender and health developments in research. Eur J Womens Stud 2007;14:9–20. 7 Cheng LF, Tsai CC, Kuhlmann E. Mainstreaming gender into healthcare and policy: learning from international experience. Taiwan J Stud Sci Technol Med 2011;12:251–72. 8 Ministry of Education. Gender statistics. http://www. edu.tw/pages/detail.aspx?Node=3973Page=20272& WID=31d75a44-efff-4c44-a075-15a9eb7aecdf#a. [Acces sed 14 October 2013.] 9 Cheng LF, Kuhlmann E, Annandale E. Gender mainstreaming at the cross-roads of eastern–western medicine. In: Kuhlmann E, Annandale E, eds. The Palgrave Handbook of Gender and Healthcare. London: Palgrave Macmillan Press 2010;421–36. 10 Wei MJ, Fang WH. The development of gender education curriculum in the University in Taiwan: 2001–2010. Gend Equity Educ Quarterly 2012;58: 25–32. 11 Peng YW. When bureaucrats meet feminists: exploring the progress and challenges of gender mainstreaming in Taiwan. Soochow J Pol Sci 2008; 26 (4):1–59. 12 Yang JH, Cheng LF. The project for integrating gender mainstreaming into medical education. Gend Equity Educ Quarterly 2008;43:16–24. 13 Wang WK. Curriculum and Teaching Methodology. Taipei: Wu Nan Press 2006. 14 Zelek B, Phillips SP, Lefebvre Y. Gender sensitivity in medical curricula. CMAJ 1997;156:1297–300. 15 Cammack JC, Phillips DK. Discourses and subjectivities of the gendered teacher. Gend Educ 2002;14:123–33. 16 Connell RW. Masculinities, 2nd edn. Berkeley, CA: University of California Press 2005. 17 Glick P, Fiske ST. The ambivalent sexism inventory: differentiating hostile and benevolent sexism. J Pers Soc Psychol 1996;70:491–512. 18 Glick P, Fiske ST. Hostile and benevolent sexism: measuring ambivalent sexist attitudes toward women. Psychol Women Q 1997;21:119–34.
19 http://www.ptt.cc/bbs/PttNewhand/M.1229860709.A. AE1.html. [Accessed 5 June 2014.] 20 Maxwell JA. Qualitative Research Design: An Interactive Approach, 3rd edn. London: Sage Publications 2012. 21 Cheng LF. Issue on Gender and Medical Education. Gender Equity Education Quarterly 2008;43:8–68. 22 Johnson AG. The Gender Knot: Unraveling our Patriarchal Legacy. Philadelphia, PA: Temple University Press 1997. 23 Martin E. The egg and the sperm: how science has constructed a romance based on stereotypical male– female roles. Signs 1991;16 (3):485–501. 24 Yang HC. The Campus Life and Gender: Learning Gender and Teaching Practice. Taipei: Chu Liu Press 2010. 25 Wood J. Groping Towards Sexism: Boys’ Sex Talk. London: Palgrave Macmillan Press 1984. 26 Haywood C, Mac an Ghaill M. Schooling Masculinities. Understanding Masculinities. Buckingham: Open University Press 1996. 27 Chambers C, Tincknell E, Loon JV. Peer regulation of teenage sexual identities. Gend Educ 2004;6:397–415. 28 Kan RWM, Au KP, Chan WK, Cheung LWM, Lam CYY, Liu HHW, Ng LY, Wong MY, Wong WC. Homophobia in medical students of the university of Hong Kong. Sex Educ 2009;9 (1):65–80. 29 Pascarella ET, Whitt EJ, Edison MI, Nora A, Hagedorn LS, Yeager PM, Terenzini PT. Women’s perceptions of a ‘chilly climate’ and their cognitive outcomes during the first year of college. J Coll Stud Dev 1997;38:109–24. 30 Aikman S, Halai A, Rubagiza J. Conceptualising gender equality in the research on education quality. Comp Educ Rev 2011;47:45–60. 31 Chen WC, Chu DC, Chen RC, Chang SY. Gender difference in the manpower and specialty selection among medical students and physicians: a ten-year trend study from 1998 to 2007. J Med Educ 2010;14:251–61. 32 Phillips CB. Student portfolios and the hidden curriculum on gender: mapping exclusion. Med Educ 2009;43:847–53. 33 Phillips SP, Clarke M. More than an education: the hidden curriculum, professional attitudes and career choice. Med Educ 2012;46:887–93. 34 Taipei Times. Blood testing without agreement of a gay patient, the hospital is fined. http://news.ltn. com.tw/news/life/paper/788344. [Accessed 18 June 2014.] 35 Jayakumar UM. The invisible rainbow in diversity: factors influencing sexual prejudice among college student. J Homosex 2009;56 (6):675–700.
Received 25 January 2014; editorial comments to author 24 February 2014, 29 July 2014; accepted for publication 17 September 2014
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CONTEXT Gender sensitivity is a crucial factor in the provision of quality health care. This paper explores acquired gendered values and attitudes among medical students through an analysis of the hidden curriculum that exists within formal medical classes and informal learning. METHODS Discourse analysis was adopted as the research method. Data were collected from the Bulletin Board System (BBS), which represented an essential communication platform among students in Taiwan before the era of Facebook. The study examined 197 gender-related postings on the BBS boards of nine of 11 universities with a medical department in Taiwan, over a period of 10 years from 2000 to 2010. RESULTS The five distinctive characteristics of the hidden curriculum were as follows: (i) gendered stereotypes of physiological knowledge; (ii) biased treatment of women; (iii) stereotyped gender-based division of labour; (iv) sexual harassment and a hostile environment, and (v) ridiculing of lesbian, gay, bisexual and transgender (LGBT) people. Both teachers
and students co-produced a heterosexual masculine culture and sexism, including ‘benevolent sexism’ and ‘hostile sexism’. As a result, the self-esteem and learning opportunities of female and LGBT students have been eroded. CONCLUSIONS The paper explores gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms. Both teachers and students, whether through formal medical classes or informal extracurricular interactive activities, are noted to contribute to the consolidation of such norms. The study tentatively suggests three strategies for integrating gender into medical education: (i) by separating physiological knowledge from gender stereotyping in teaching; (ii) by highlighting the importance of gender sensitivity in the language used within and outside the classroom by teachers and students, and (iii) by broadening the horizons of both teachers and students by recounting examples of the lived experiences of those who have been excluded and discriminated against, particularly members of LGBT and other minorities.
Medical Education 2015: 49: 321–331 doi: 10.1111/medu.12628 Discuss ideas arising from the article at www.mededuc.com discuss.
Graduate Institute of Gender Studies, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence: Hsing-Chen Yang, Graduate Institute of Gender Studies, Kaohsiung Medical University, 100 Shichuan 1st Road, San-Min District, Kaohsiung 807, Taiwan. Tel: 00 886 7 312 1101; E-mail: [email protected]
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L-F Cheng & H-C Yang failed to address issues of gender equity and some were even deemed to reproduce gender stereotypes.10
INTRODUCTION
Since the adoption of gender mainstreaming as policy by the United Nations Fourth World Conference on Women in 1995, some leading universities in Europe, North America and Australia have actively sought to integrate gender into medical education.1–5 Many research papers on medical education have pointed to the importance of including gender perspectives to promoting the quality of health care.1 Physicians who have acquired enough knowledge and understanding of gender differences in symptoms and risk factors in various diseases, and adapted their diagnoses and treatments accordingly, are shown to be able to more effectively treat their patients.1,6,7 These papers further point out that in the majority of biomedical textbooks and education programmes, gender issues are still perceived as representing ‘women’s problems’: differences of sex and gender, as well as in physiological symptoms, are often simplified without taking into account their complex social-cultural context; knowledge of health and medicine still appears to be ‘male-centred’ to a great extent, with the male physiology regarded as the ‘standard’ norm, and gender-associated differences are often downplayed or ignored in diagnosis.1,3–5 In Taiwan, the practice of biomedicine has for many years represented one of the most privileged professions and is in part a legacy of Japanese colonial rule, which ended in 1945. Women have been admitted into the profession only since the mid1950s, and despite recent changes in gender equity, male students still predominate. For instance, the profile of the student body shifted from 77.6% male and 22.4% female in 1997 to 67.4% male and 32.6% female in 2012.8 The professional community likewise remains male-dominated; the evidence points to the ongoing permeation of the profession by a masculine culture that sets the norm and receives little challenge.9 The unequal gender ratio and the perceived dominance of masculine culture in the medical profession and medical education were the targets of reform when the Gender Equity Education Act was promulgated in 2004. The Act requires that universities set up courses related to gender equality. According to a study on gender education curricula developed in Taiwanese universities from 2001 to 2010, although the quantity of courses had grown, they remained obviously inadequate; many courses claimed to be gender- or female-related, but in fact
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In 2006, the Medical Education Committee of the Ministry of Education commenced a series of programmes intended to integrate the concept of gender equality into medical education. Its approach was to conduct annual seminars targeting teaching staff, aiming to raise their gender awareness and gradually to infuse gender into the formal curriculum, thus initiating a ‘trickle-down’ effect on the outlook of students.9 From this it can be seen that medical education practitioners had taken on board the importance of cultivating awareness of gender equality and its values on campus. The evidence so far raises doubt as to the effectiveness of this top-down approach11 and suggests that a thorough understanding of how students learn gender values through daily interactions on campus may be a vital part of the reform of medical education.3– 5,9 To this end, we sought to investigate whether and how any hidden curricula may be at play. In their proposal for integrating gender into medical education, Yang and Cheng12 draw our attention to the effective power of such a hidden curriculum in medical training. How can such a hidden curriculum be understood in the context of medical education? There are two closely related interpretations of the mechanisms of such a curriculum. One implies a general influence on student development through the cultivation of values and attitudes that are derived from the material and cultural environments, such as buildings, equipment and campus rituals, as well as from personal relationships, such as in teacher–student relationships and interactions among students.13 To describe the other interpretation, Zelek et al.14 draw our attention to the content, language and process of formal curricula: ‘What is the “hidden curriculum”? When examples about women are appended in parentheses, are always presented after those about men or are limited to reproductive issues?’ Initiatives such as the Women’s Health Interschool Curriculum Committee of Ontario in Canada may be one example of the counter-approach to such curricula. Zelek et al.14 emphasise the significance of diversity of presentation and the usage of non-gender-biased language in communication with statements such as: ‘Female and male patients should be represented in equal numbers in examples, problems and case studies’ and ‘Terms that
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Learning about gender on campus trivialise or stereotype women should be eliminated.’ Both views inform us that the hidden curriculum exists within and outwith formal medical classes; it is intertwined with formal teaching and informal learning. What students acquire outside classes will be brought into their formal education; equally, if the medical education integrates gender perspectives, then students will carry these into their daily and professional practice in the future. Given the potential influence on students of aspects within the hidden curriculum, we wished to explore the gendered world of medical students by analysing the language they use in social communication on campus.15 The presentation of this language can provide a glimpse of the sociocultural context in which the speakers are located, and the gender values and attitudes they possess and express. Theoretical framework We adopted two related theoretical frameworks for analysing the presentation of language. One of these, coined by R W Connell,16 refers to hegemonic masculinity and subordinate masculinity. Hegemonic masculinity is used here to indicate a pattern of practice that sustains men’s dominance over women, masculinity over femininity, and heterosexuality over homosexuality. According to this approach, Western society privileges a number of characteristics, such as violence, aggression, courage, toughness, risk-taking, adventure, emotional restraint, competitiveness and success. Boys and men internalise these characteristics in daily interactions with family members and at school and in the workplace; these masculine characteristics are also reinforced via cultural, economic and legal arrangements. Hegemonic masculinity justifies the dominance of heterosexual men and the subordination of homosexual and effeminate men who exhibit physical weakness or emotional expressiveness. Homosexual and effeminate boys and men often run the risk of being socially, culturally, legally and economically excluded and discriminated against. A key feature of hegemonic masculinity, according to Connell,16 is a brotherly complicity to privileged masculine characteristics, for which there appears to be much evidence among the university students discussed in this paper. The other framework refers to the ambivalent sexism theory suggested by Glick and Fiske,17,18 which
appears to work well in attempts to explain the daily interaction of medical students on campus. These authors point out that both ‘benevolent sexism’ and ‘hostile sexism’ derive from the power structure of patriarchy, which assigns superiority and inferiority to males and females, respectively. ‘Benevolent sexism’ is here represented in the form of protection by the father and brother, idealised female images, and the stereotyping of physical weakness and emotional expressiveness in women and LGBT (lesbian, gay, bisexual and transsexual) people, whereas ‘hostile sexism’ emphasises the negative values and images of femininity, and practises surveillance and control, and exclusion with hostility. The present study focuses on the gender values and attitudes that medical students acquire from such hidden curricula, and endeavours to establish what kind of information they convey. The study aims to point out areas which formal and informal medical education might seek to target and strengthen in future reform. We indicate how these may provide starting points for the integration of gender in medical education from the bottom up, and thus assist education reformers in their efforts to locate and resolve such problems.
METHODS
This study was conducted across nine of the 11 universities in Taiwan that maintain a medical department. The data were collected from all Bulletin Board System (BBS) forums run by medical departments. The BBS was an interactive digital communications system, popular among students from the mid-1990s to 2010, when Facebook arrived in Taiwan, which functioned mainly as a tool through which community members could circulate information about activities, make comments on social and sporting events, express concern over certain issues, and relax by chatting and joking. Each board included a student elected as administrator; this person was responsible for controlling the discussion board content and entitled to mark or delete posts. The BBS system would also automatically delete posts when the board exceeded its storage limit, and would retain only the marked items.19 The postings collected were sourced from openaccess web-based archives, which include 19 666 marked posts not deleted by either the administrator or the system, of which around 1% (i.e. 197 items posted during 2000–2010) were found to be gender-related. Furthermore, 94% of these were posted by male students.
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L-F Cheng & H-C Yang We found Internet forums were ideal for understanding the gender-related values and attitudes of the posters, as BBS users often wrote messages no longer than one or two lines of text under no pressure or in a light-hearted and casual style; therefore the discourse of comments and jokes is likely to reflect their undisguised views and values. Discourse analysis was used to analyse the data in a process during which we noted the paradoxical discourse of both the use of language and the maintaining of silence. As Cammack and Phillips15 have noted, an individual’s comments or jokes reflect submission to certain dominant discourses which shape self-understanding and reconfirm certain social-cultural norms. We began by sorting the data according to the theoretical concepts. The first step was to sort the data according to the following concepts: display of masculine power (20.7%); display of feminine power (0%); unequal treatment of women (33.0%); women’s protest (1.5%); equal treatment of women (0%); attitudes towards LGBT people (16.5%); LGBT protest (0%); benevolent sexism (14.3%); hostile sexism (9.0%), and other (5.0%). As the year 2004 saw the promulgation of the Gender Equity Education Act in Taiwan, in order to grasp its impact or the change caused, each category was subdivided into two periods: ‘before 2004’ (32% of total data), and ‘from 2004’ (68% of total data). The second step was to make cross-comparisons of the data and select posts that were rich in social meanings and representative of issues. The final step was to focus on five mutually exclusive categories to yield results. The postings discussed in each category represented typical gender-related values and attitudes mostly shared among male students and teachers. For the sake of research ethics, sources were marked with codes in order to allow us to track the medical departments for discussion; thus a quotation marked as ‘2009/A/M’ indicated the post had been written in 2009 by a male student from university A. Some quotations were edited, but this was done in a way that ensured their original meaning was unchanged. Last but not least, the validity of the study should be addressed.20 These 197 postings, left on the BBS for open access, were selected either by the administrators or randomly by the system; it is not possible to establish in which social context some posts were deleted and some kept. However, we argue that the validity of data interpretation can be ensured in the following ways. Firstly, the postings we identify as having distinctive characteristics and rich social
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meanings are mostly controversial or more popular than average. Secondly, the gender issues raised in the data must have some public significance rather than just personal importance. Thirdly, consultations with female medical students with feminist awareness about ‘shared lecture notes’ and general interactions on the BBS confirmed our findings. Fourthly, the first author has been actively engaged in organising annual seminars on gender equity for medical teaching staff for the Ministry of Education and edited a special issue of a journal on integrating gender issues into medical education in 2008.21 Finally, both researchers have been teaching and researching in gender studies for over a decade, and educators for medical professionals since 2006; they are confident of detecting the exercise of masculine power and practice of sexism as illustrated in the postings.
RESULTS
We have noted that sexism is mediated through the use of the language of gender discrimination and sexual harassment; we shall reveal that sexual prejudice and hostility towards sexual minorities are repeated in various forms in the writings on the BBS. The following are the most distinctive characteristics shared by medical students and sometimes teachers. Gender stereotypes of physiological knowledge Physiological differences between males and females have long been used as ‘evidence’ to justify the unequal treatment of men and women in society; in our project, we found a similar pattern in wisecracking on the BBS: Let me tell you all, the easiest way to remember the positions of the aorta and the vena cava is to follow the rules of Chinese palm reading which take [the] male left hand and [the] female right hand. The aorta is an active one so is located at the left to spine, vena cava is a quiet one so at the right. Why is the liver on the right of the spine? Because it produces the extra blood women need for their monthly periods. Why are testicles located at the lowest part of [the] male body? Because men have to kneel down to make a wedding proposal. (2003/D/M) Such puerile connections between gender and body function may be regarded as harmless at first sight,
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Learning about gender on campus yet they may also be perceived as serving to perpetuate and reinforce gender stereotypes. Jokes and wisecracks focusing on body parts were also made by teaching staff. For example, one male student refers to a lecture in which he quotes the teacher as saying: These are two large tumour cells growing on either side of the artery; they are just like the testicles on all you male students. This particular student adds a comment to this:
the structures of the heart and lungs, he would not publicly disgrace them. However, he really gave me a hard time when I failed to do so; probably it meant I was the tough guy, the king of the manly guys, so I deserved it? (2006/B/M) A teacher’s differential treatment of female and male students in class can be understood as a message confirming a widely spread gender attitude: that men should be taken more seriously than women. Male students also teach one another how to become a man with authority:
Well, mine are actually a lot bigger! (2005/H/M) Same-sex anal intercourse also appears as a frequent source of classroom amusement. One pathology professor is quoted as saying that a high proportion of tuberculosis patients are unaware that they are human immunodeficiency virus (HIV)-positive and that medical personnel might waste a lot of time carrying out all kinds of tests before discovering a patient’s HIV status. A student who found this comment particularly amusing pasted it on the BBS and wrote: But how can we be expected to carry out a rectal examination each time a TB patient comes to seek our help! (2008/F/M) Biased treatment of women Female students constitute one-third of medical students. In this minority position, they appeared to be treated in ways seemingly contradictory but consistent with patriarchal order. In other words, they were constructed as being helpless, needing to be tamed and as sexual objects. Female students tend to be taken under the wing of male contemporaries, implying that they are weak and incapable, which is in keeping with a traditional image of femininity. Messages to this effect appear repeatedly in BBS discussions:
If your girl asks you to go to a movie while you are playing basketball, just tell her: “Shut up, don’t interrupt while a man is playing sport.” I bet she will admire you even more. (2010/E/M) This is regarded as an instance of ‘taming’ a woman and learning to be a ‘proper’ man on campus. Cracking jokes with sexual innuendo was found to be a common practice in social activities as well as in BBS messages, and appeared often to be regarded as harmless fun by the majority of male students: Female students whose tits are too small to show any cleavage would definitely have difficulties forming alliances with male students. (2006/G/ M) Similar postings present themselves as expressions of humour: Male students in the medical department are handsome and talented; the females are famed for their huge tits. (2004/H/M) Female students in the nursing department have hot and spicy figures and great looks; if anyone wants a date, leave me a message. (2002/I/M) Stereotyped gender division of labour
Please demonstrate your masculine power; if a female classmate is incapable of running the computer program, you should give her a hand. (2007/A/M) Another comment conveys a similar message: Teacher W often has a soft eye for women students; if they failed to give the correct answers to
We found that a stereotyped gender division of labour predominated in many activities as recorded on the BBS. Here are five examples for discussion. The first posting, referring to requirements for a ceremony to acknowledge body donors, states: Two flower presenters are called for from each class. These should be one male and one female,
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learning about gender Learning about gender on campus: an analysis of the hidden curriculum for medical students Ling-Fang Cheng & Hsing-Chen Yang
CONTEXT Gender sensitivity is a crucial factor in the provision of quality health care. This paper explores acquired gendered values and attitudes among medical students through an analysis of the hidden curriculum that exists within formal medical classes and informal learning. METHODS Discourse analysis was adopted as the research method. Data were collected from the Bulletin Board System (BBS), which represented an essential communication platform among students in Taiwan before the era of Facebook. The study examined 197 gender-related postings on the BBS boards of nine of 11 universities with a medical department in Taiwan, over a period of 10 years from 2000 to 2010. RESULTS The five distinctive characteristics of the hidden curriculum were as follows: (i) gendered stereotypes of physiological knowledge; (ii) biased treatment of women; (iii) stereotyped gender-based division of labour; (iv) sexual harassment and a hostile environment, and (v) ridiculing of lesbian, gay, bisexual and transgender (LGBT) people. Both teachers
and students co-produced a heterosexual masculine culture and sexism, including ‘benevolent sexism’ and ‘hostile sexism’. As a result, the self-esteem and learning opportunities of female and LGBT students have been eroded. CONCLUSIONS The paper explores gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms. Both teachers and students, whether through formal medical classes or informal extracurricular interactive activities, are noted to contribute to the consolidation of such norms. The study tentatively suggests three strategies for integrating gender into medical education: (i) by separating physiological knowledge from gender stereotyping in teaching; (ii) by highlighting the importance of gender sensitivity in the language used within and outside the classroom by teachers and students, and (iii) by broadening the horizons of both teachers and students by recounting examples of the lived experiences of those who have been excluded and discriminated against, particularly members of LGBT and other minorities.
Medical Education 2015: 49: 321–331 doi: 10.1111/medu.12628 Discuss ideas arising from the article at www.mededuc.com discuss.
Graduate Institute of Gender Studies, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence: Hsing-Chen Yang, Graduate Institute of Gender Studies, Kaohsiung Medical University, 100 Shichuan 1st Road, San-Min District, Kaohsiung 807, Taiwan. Tel: 00 886 7 312 1101; E-mail: [email protected]
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Learning about gender on campus intent was calculated to disturb and punish. One female student posted on the evening before an examination: What a swine! He stole the identities of three different classmates and made postings declaring his love for me, it really bothered me. You may think you are under a lot of pressure from your studies, and find this an amusing diversion, but you made me fret all night, and I was unable to prepare for my calculus exam. (2007/A/F) Ridiculing LGBT Notices ridiculing LGBT people and issues appeared many times on the BBS. Expressions such as ‘playing gay’ and ‘gender disorder’ are often jokingly exchanged among students. For instance, a birthday greeting might be: Hope you get rid of your sissy style next year. (2008/C/M) Some female students share such sentiments but express themselves in a milder manner: I hear that those departing the women’s basketball team all become stars on the softball team, so why don’t you try your luck with the softball team? (2009/B/F) But. . . I hear there are lesbians on that team, so better to go for table tennis. (2009/B/F) This might be classified as soft homophobia conveying a sense of refusal. Students often discuss films on BBS boards. Our data included posts made by students after watching a Spanish film entitled Bear Cub, which was shown on campus and is about a caring relationship between an HIV-positive gay dentist and his nephew: Those in [the] dentistry department should be alert! Fortunately, we are in [the] medical department. (2007/F/M) How come I get the impression the film is about sexual dysfunction? Am I mistaken? (2007/F/M) What a bad influence on the nephew! (2007/F/M) Another discussion about the film Boys Don’t Cry also appears to illustrate a general lack of any sense of
the experience of oppression of LGBT medical students. This film is about a transgender person who is beaten, raped and murdered by male acquaintances after they discover he is physically female. One female student posted: . . .one doesn’t have to accept the transgender, but please do not harm them. (2010/F/F) This elicited the retort: She was killed not for being transgender; it was due to the ways she chased the woman she loved. (2010/F/M) The latter comment suggests an individualistic approach towards such tragedy, which does not acknowledge the social hostility that is endured by homosexual and transgender people, and accuses the transgender character of improper behaviour. One post condemned a teacher’s explicit expression of his moral views in class: No sex before marriage? Homosexuals cause social chaos? Teacher, how can you come up with such crap? (2008/G/M) The fact that some teachers felt no inhibition in openly expressing hostility towards LGBT groups may be seen as an alarming phenomenon for medical education reformers.
DISCUSSION
In the context of a hidden curriculum, the sexually discriminatory language and its gender scripts on the BBS provide a learning platform for reconfirming patriarchal values. Using this approach, we can identify two distinct characteristics in terms of learning gender on campus. Heterosexual masculinity as the culture Western readers might find shocking the open use of degrading words and jokes about women and LGBT groups on the BBS. However, the absence of any inhibition in expressing sexually discriminatory attitudes and words on the part of male students reflects the culture of hegemonic masculinity in the community of medical students in Taiwan, and the resulting laughter and appreciation of such jokes also foster an atmosphere that privileges malecentred and male-defined values.16,22
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L-F Cheng & H-C Yang Physiological knowledge is supposed to be ‘neutral’ and not to hold any gendered association. However, as Emily Martin’s23 famous critique points out, the interaction between the egg and millions of sperm has been constructed by scientists as a romance based on stereotypical male and female roles. As we have noted, the acts of making puerile connections between female menstruation and the fact that the liver is located to the right of the spine, between the location of testicles and the fact that a man may kneel to make a marriage proposal, as well as between male sexual prowess and two large tumour cells located on either side of an artery are also based on stereotypical male and female roles. Even the pathology professor makes a scientifically unsound connection between HIV positivity and rectal examination. There is a long tradition of wisecracking in the medical community in Taiwan in which physiological knowledge is often presented in the form of gendered stereotyping, and it is this social context that gives rise to the postings on the BBS. The pleasure gained from commenting on women’s breasts and figures, arguing for adding a picture of a nude woman in the shared lecture notes and sharing the news about dating girls with ‘spicy figures and great looks’ can be seen as a means of bonding among the ‘heterosexual brotherhood’. Whether they are collectively endorsing an unmarried teacher’s desire for wealth and a wife, or individually learning to show male authority over a girlfriend, these are ways by which men can reconfirm their masculine subjectivities, reinforce patriarchal control over women and practise surveillance over one another.24–27 One area of comment that arises frequently concerns male boasting about sexual prowess. This tends to be humorous and yet boastful, such as when a male student claims to have giant testicles, echoing the masculine sentiments expressed by the teacher in the class. Competition among males, especially in terms of sexual prowess, is an important aspect of masculine culture. Had anyone from the minority group of female students protested against such jokes, she would probably have faced tremendous pressure and been labelled as ‘unfriendly and fussing over nothing’. The cautious and hesitant image of female students we receive can be explained by the isolation and exclusion they experience in such a male-dominated learning environment. Female students showed themselves to be uncomfortable in joining in such discussions and chose instead to keep a low profile or to play only a marginal role in interaction on the BBS.
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The devaluation of subordinate masculinity on the BBS often occurred in the form of jovial banter. The birthday greeting ‘. . .hope you get rid of your sissy style next year. . .’ conveys the message that a ‘sissy style’ does not fit in and may lead to exclusion by the male community. The discussion of the film Bear Cub again reveals negative views about homosexual and HIV-positive people, who are treated as laughing stocks not only among medical students. The joke used by the class teacher who suggested that rectal examination could be used to determine HIV-positivity in homosexual men is a typical one. It suggests some real inner fear of catching acquired immune deficiency syndrome (AIDS) in medical practice, as well as an unspoken yet pervasive homophobia. Sexism caused by stereotyping and ignorance The examples illustrated herein provide ample evidence that stereotyped gender images are deeply ingrained. In their postings, students associate strength and power with the male, and inactivity and passivity with the female. For example, the ceremony held to express gratitude to body donors is regarded as an emotional occasion and thus female students are expected to present the flowers. Elsewhere, it seems to be perceived as caring to offer to help a female student to run a computer program, or to assign to women students only the ‘feminine’ jobs such as reception duty, cooking, secretarial tasks and cheerleading, while male students take on the ‘hard and heavy’ jobs. Paternalistic protection is also demonstrated in differential treatment in teaching. Teachers’ protective attitudes effectively imply that they do not expect high levels of academic achievement from women students and hence there is no need to push them. This undemanding attitude towards women students in their academic pursuits signals their exclusion from the inheritance of knowledge, whereas placing high expectations on male students conveys the message that they are seen by teachers as their potential successors. These attitudes can be appropriately described as representative of benevolent sexism towards female students.17,18 Benevolent sexism is often confused with well-meaning acts of protecting and caring. It is in reality an exercise of paternalistic power over a minority and marginalised group. In the long run it exerts at least two kinds of invisible impact. One is to assign the decorative, domesticated and protected roles to women students, trap them in an invisible cage of
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Learning about gender on campus self-devaluation and self-constraint and exclude them from taking on challenging roles; the other is to reinforce traditional gendered roles in the selfidentity and projected identity of male and female students, which they will carry into their professional workplaces and future family lives. Such harm is beyond measurement and should not be the purpose of medical education.24 The postings on the BBS give an impression that female students were subject to only benevolent sexism, whereas LGBT students experienced hostile sexism.17,18 Overall LGBT individuals and issues were the objects of much teasing and bantering on the BBS, on which the homophobia expressed is even worse than the misogyny. We believe this homophobia derives from stereotyping and ignorance, as well as the practice of control and surveillance in a culture of hegemonic masculinity, which is very heterosexual by nature.16 The BBS discussion of the film Boys Don’t Cry indicates that ignorance of the social, cultural and even economic predicaments of LGBT groups is prevalent among medical students. It is surprising to see that LGBT status retains a negative image as representing a ‘disorder’ or ‘dysfunction’ that should be corrected or cured, even as late as 2007, given that such categories had been removed from the Diagnostic and Statistical Manual of Mental Disorders (DSMII) as early as 1973. Moreover, comments such as ‘homosexuals cause social chaos’, expressed in a class by a teacher, may inflict harm on invisible LGBT students who remain silent in the classroom. If no-one dares to stand up against such homophobia, it is seen to be acceptable. A study on homophobia among medical students in Hong Kong echoed the situation in Taiwan, indicating the importance of developing an LGBT-friendly curriculum.28 Hostile sexism is demonstrated not only towards LGBT groups, but also towards women on some occasions. As mentioned before, the display of a nude female in the shared lecture notes and the creation of an atmosphere of constraint have served to prevent women students from raising forceful protests. These are some of the effects of a misogyny that is deeply embedded in a patriarchal culture and reduces women to nothing more than objects of male sexual desire. Another case of relevance involves the hoax love messages sent to a female student to cause emotional disturbance before an examination. This would no doubt be regarded as an act of sexual harassment. This behaviour is likely to have derived from a hostile atmosphere that has existed for some time, rather than representing a unique incident of mischievous misconduct.
Pascarella and her colleagues, having examined the state of play on American campuses, suggested that the longstanding ‘chilly climate’ would have serious negative impacts on the self-esteem and academic development of female students, whereas a friendly and supportive campus network would enable the academic performance of female students to flourish.29 We would also apply this to students in LGBT groups. Our study shows that both heterosexual masculinity as representative of the dominant culture and sexism caused by stereotyping and ignorance are two distinct characteristics of the hidden curriculum; they are in fact co-produced by teachers and students through interaction within and outwith formal medical education, as well as in formal teaching and informal learning.
CONCLUSIONS
Following the argument promulgated by Aikman et al.30 that ‘education quality demands an analysis of gender dynamics in the wider social context of the lives of boys and girls’, the present paper has explored the role of gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms that reflect mainstream gendered relations in Taiwan during 2000–2010. It is also noted that both teachers and students, whether they have formal medical classes or informal extracurricular interactive activities, contribute to the consolidation of such norms. The analysis of BBS messages has thrown new light on the dark side of this gendered subculture and sends out alarming signals to educators. It brings to our attention that it is important to break the silence of sexual minorities and marginalised people and to make the invisible become visible. One might wonder how heterosexual masculinity and stereotyped sexism prevalent in the subculture of medical students may affect women physicians in the workplace and the quality of the care delivered to diverse patients. There is no direct evidence to prove the influence of the hidden curriculum on these matters; however, two examples may provide a glimpse. Firstly, according to a study on gender differences in specialty selection among novice physicians in 2007 in Taiwan,31 males tended to select internal medicine, surgery and emergency medicine, the former requiring doctors to spend more time on reading and solving complicated cases, and the latter demanding physical strength and risk-taking; these specialties are closely associated with masculinity. The top four
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L-F Cheng & H-C Yang favourite specialties of women physicians were paediatrics, family medicine, obstetrics and gynaecology, and psychiatry,31 all of which are closely related to family care. The selection of specialties in novice physicians can be perceived as following the traditional gender division of labour. This is by no means true only of Taiwan. Two studies on the impacts of the hidden curriculum on gendered career choice showed similar results in Australia and Canada. Female medical students were found to prefer ‘female-friendly’ career choices, viewed motherhood as a negative impact on their medical careers and expected to put their families before their careers.32,33 Secondly, as mentioned previously, medical teachers and students tend to associate AIDS with homosexual men and are worried about contracting HIV in medical practice. According to a news story in June 2014, a hospital in southern Taiwan was fined because a homosexual patient who had requested surgery was given an HIV blood test without his consent.34 What are the recommendations for change? The present findings give rise to three tentative directions for further education reform. Firstly, physiological knowledge should be separated from stereotyped gender association in teaching. Goodquality teaching requires illustrations to be interesting and humorous, neither of which should be fostered at the expense of women by using them as sex objects or LGBT groups by making them laughing stocks. The cases discussed in this study can serve as examples for lively discussion and selfreflection in class. Secondly, it is essential to promote gender sensitivity in the use of language in class by teachers and in extracurricular activities by students. As Zelek et al.14 point out, ‘. . .language should be examined to determine whether the words used to convey information subtly promote and maintain stereotypes about either sex or are emancipatory.’ The postings on the BBS can be elaborated to form case studies and teaching materials for use in formal medical classes. It is expected that through conversation, discussion, consciousness-raising and self-reflection, both teachers and students can gradually come to realise how heterosexual masculinity works in practice and how sexism can inflict harm on many silent minorities. Thirdly, the ignorance about LGBT issues as disclosed in the above analyses can be gradually diminished by telling the stories of how these minorities have faced exclusion and discrimination. The close examination of personal experience has been shown to be vital to transforming individual awareness.24 Recounting of the lived experiences of
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these invisible minorities can slowly erode the bias and expand the horizon of medical students, and, it is hoped, contribute towards their becoming good doctors. A longitudinal study of 13 881 college students in the USA conveyed an optimistic message indicating that individuals can become more accepting of LGBT relationships after 4 years of college life, thereby proving that students have the capacity to transform prejudice by broadening their life experience, including by learning gender equity on campus.35 As BBS postings can be deleted by the board administrator or randomly by the system, it is impossible to track any valid changes in the last 10 years. However, despite this limitation, awareness of gender equity in Taiwanese society has certainly progressed since the implementation of the Gender Equity Education Act in 2004. If the suggested directions for education reform and the promotion of a gender-sensitive medical pedagogy come to be adopted and practised in Taiwan, the prevalences of both benevolent sexism and hostile sexism, as well as the domination of heterosexual masculinity, are likely to diminish in medical subculture. Medical education reform must focus not only on the integration of gender perspectives into the formal biomedical teaching programme, but also on eradicating the sexist and homophobic hidden curriculum in which the dominance of hegemonic masculinity and sexism are at play. In other words, teaching staff should take gender equity training seriously, and medical students should be required to take gender equity-related courses. Both strategies may reinforce the cultivation of gender sensitivity and diminish the subculture of misogyny and homophobia.
Contributors: L-FC contributed to the study conception and design, and the acquisition, analysis and interpretation of data. H-CY contributed to the study conception and design, and the analysis and interpretation of data. Both authors contributed to the drafting of the paper. L-FC conducted its critical revision. Both authors approved the final manuscript for publication. Acknowledgements: this work is supported by J. Y. Gu and T. H. Wang by their assistance with data collection. Special thanks to T.H. Wang for assisting draft preparation. Thanks to Paul Crook, Xue Feng and Jocelyn Watson for proofreading, your invaluable assistance make the texts shine. Funding: Taiwan National Science Council No. NSC992511-S-037-002. Conflicts of interest: None. Ethical approval: Not applicable.
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Learning about gender on campus
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Received 25 January 2014; editorial comments to author 24 February 2014, 29 July 2014; accepted for publication 17 September 2014
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