He-man womun hater’s snub

Medicine, sexism, and the amorality of history

Dr. Elizabeth Blackwell

By Anonymed (an anonymous Canadian Doctor)

Medicine is so broad a field, so closely interwoven with general interests…that it must be regarded as one of those great departments of work in which the cooperation of men and women is needed to fulfill all its requirement — Dr. Elizabeth Blackwell

Like many a Millennial man-child, my relationship with my mother-in-law is somewhat…fraught. She comes from a generation of don’t-rock-the-boat WASPs who view opinions as private things and dreams, by definition, as the stuff of pipes. The virtuous thing to do is to keep one’s head down, do what needs to be done, and be thankful for the chance to do so. Anything else is courting trouble and risk. 

I understand why someone like that might not be my biggest fan. By her lights, I’m a toddler with a checking account. Times were different when she grew up. Values were different. Opportunity was a privilege, not a right, and one that was denied to many. It was a very different time for women in particular. Not long ago, as she was rummaging through some old basement boxes, she found an evaluation she’d received during the final stages of her training as a pharmacist. It was 1977, and men were, well, super sexist - often in a kind of benign, paternal way, but still. After what sounded like a successful internship, her male preceptor wrote that she would make a good pharmacist “despite being of the feminine gender.” It’s not like she couldn’t go outside without an escort or anything, but I think I’d have worded it a little differently.

Things have changed dramatically in the intervening years, across all manner of educational endeavor. My medical school graduating class was about seventy percent female, which was not an anomaly even years ago. By nearly every metric, healthcare is now a woman’s game. But, as my mother-in-law can attest, it wasn’t always the case. 

Like women's foray into the workforce in general - an experiment, it should be remembered, we’ve only truly been running for sixty years - their integration into the medical profession was slow and often painful, with barriers aplenty along the way. While it is easy to find examples of women breaking the medical glass ceiling throughout history, they tend to be sporadic exceptions rather than vanguards of change. The Greeks had Metrodora. The Egyptians Meit Ptah. Even retrograde medieval Christendom had Hildegard of Begin (though she was mostly a midwife). But in the same way that leaders like Benazir Bhutto were not a reflection of women's progress in the Islamic world so much as a testament to the fact that clan and family power can sometimes override misogynistic norms, the early women of medicine were typically privileged and unique. It wasn't until centuries later that they would break through in a more sustained way. Even then, however, progress was far from linear.

The official honour of being North America's first female physician is typically bestowed to Dr. Elizabeth Blackwell, who attained that distinction in 1849. At the time, medical colleges were largely restricted to men and, unsurprisingly, Dr. Blackwell's path was difficult. She was rejected by every mainstream medical university she applied to despite being by all accounts eminently qualified. Undeterred, she then applied to a number of smaller and less-prestigious colleges, but even then was accepted to just one: New York's Geneva Medical College. To read the account of her admission and life in medical school is to gain a window into the stultifying sexism of the time. Unfortunately, Blackwell hadn’t found the one college whose administrators believed in the equal capabilities of women. They were progressive in the sense that they were wary of rejecting a qualified applicant solely on the basis of sex, but instead of just admitting her on that basis they chose, strangely, to put the decision to the (all male) student body. The story goes that the majority of the students thought it was a joke, and, in the way voters in banana republic sham-elections have occasionally done, inadvertently approved the first female medical student in the United States.

In the years following Blackwell's breakthrough, more and more women were admitted to a select number of medical institutions in the United States. Canada was very un-Justin Trudeau at the time (though I'm sure blackface was still cool) and admitted none. Canada's first female physician, Dr. Emily Stowe, was educated 20 years later at the New York Medical College for Women. The number of women in medicine remained paltry, but it was enough to establish a foothold in the profession that seemed permanent and ripe for growth. Unfortunately, history doesn't always work out the way it ought to have.

For all their virtues, many of the colleges that admitted women were a far cry from our modern medical institutions. In the historical record, both Blackwell and Stowe are described as trailblazing women (which they clearly were), who entered in such and such a year and went on to become such and such an icon. However, medical schools at the time were largely unregulated, unstandardized and produced graduates with highly disparate training and skill. This wild west was arguably the reason that pioneers like Blackwell and Stowe were able to do what they did, and in this sense we should perhaps be grateful for the disarray. But this wide variability also led to what happened next, which would impede the success of women in medicine for decades to come.

Even in the late 19th century, when medicine was still in its technological infancy, it was clear that some kind of standard was needed if North America was to progress in the field (and keep pace with their more advanced European counterparts, particularly zee Germans). In 1909 the American and Canadian governments recruited Abraham Flexner, an education expert, not a physician, to study and report on the standards and practices of every one of North America's 115 medical colleges. By this time, the poorly-regulated profession had produced women's hospitals, Black hospitals, women's medical colleges and Black-only medical schools. Medicine was becoming more diverse in every sense of the term. The Flexner report changed all that.

His overhaul reshaped medical education. Dubbed the "father of the modern medical school", Flexner's call for increased education standards for admission, better basic science training, structured clinical experience, and evidence-based teaching and research standardized medical training and primed the profession for the unbelievable technological advances that were to come.

His report came with costs, however - the most immediate of which was its effect on sex diversity in the profession. In 1909, approximately 9% of medical school graduates were female. They were still vastly underrepresented, but their numbers were growing. After the Flexner recommendations were implemented, that number would plummet to 2.9% over the next two decades. Why? Was it sexism? Well, yes, but not directly. Those schools that had increased their female numbers, like Blackwell and Stowe's alma maters, were very often the same schools that did not meet the standards for quality as set out by Flexner. The high-end schools had not been welcoming of women to their shame, but the reality is that many of the medical degrees obtained by women in that era were subpar. I don't know Flexner's mind, and by some accounts he didn't think women were especially apt for medicine. In response to his work’s effect on female medical graduates, he once replied: “true enough, medical schools generally have shrunk; but as the opportunities of women have increased, not decreased, and within a period during which entrance requirements have, so far as they are concerned, not materially altered, their enrolment should have augmented, if there is any strong demand for women physicians or any strong ungratified desire on the part of women to enter the profession. One of the other of these conditions is lacking - perhaps both.” Sounds pretty misogynistic by 2023 standards, but his report was not intended to reduce women in medicine. Sexist societal norms made women collateral damage in a necessary reform project. 

There aren’t a lot of lessons to learn here (then why is he boring us with this!?!). History is history. It happened and there is no changing it. I’m glad that things are different now. While the feminization of medicine has had its downsides - physicians now talk about their own “wellness” more than that of their patients, full-time practice is less and less common, and toilet humour is being flushed down the…lavatory - I don’t want to live in a world where we condescend to people based on their gametes. And Dr. Blackwell was surely right to say that medicine is such a grand undertaking that we need all genitals on deck. However, recent times have demonstrated how pathological things can get when we’re too hard on our forebears. If we can’t sympathize with history’s perpetrators as well as its victims, we’re unlikely to view the present clearly. In this case, there was a fork in the road - women were either going to get a (more) equitable share in a flailing and superstitious pseudoprofession, or sexist scraps from the table of one of the most important professions in history. 

It wasn't until the latter half of the 20th Century that the numbers of women in medicine reached where they had been in the late 19th, and it took decades more to reach something like parity. This is a pity of course, and I would certainly have preferred that a denunciation of discrimination based on sex (and race) be part of Flexner's recommendations. Alas, it was not, and though it’s easy for me to say, I have a hard time wishing he hadn't made the recommendations at all.

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Thanks for reading. For more from this author read, Tradition and contrition: In the name of reconciliation, Canadian medicine has embraced pseudoscience

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