Every day, female doctors experience ingrained sexist attitudes, such as being labelled "aggressive" or "hormonal" when expressing strong opinions. Not only are they paid far less than their male colleagues, but they're also outnumbered in nearly every speciality. Emma Russell explores the alarming extent this "boys' club culture" is being blamed for undervaluing women's health. Because while gender bias is wrong in any workforce, in the health system, it can kill.
Angela Lim smiles through frustration as an older male colleague taps on her shoulder and says: "You speak really well, not just a pretty face."
The 31-year-old Aucklander has a Bachelor of Medicine from the University of Auckland and completed sabbatical research on inequity in paediatric skin infection hospitalisations at Harvard School of Public Health.
She is the chief executive of a mental health social enterprise and has sat on 15 boards - more, she says, than the man who thought her looks were as important as her words.
Women working in medicine, she says, face scepticism from male peers and, worse, other women. But the snide comments, she says, only scrape the surface of a much bigger issue.
A Weekend Herald investigation has found female specialists are outnumbered and outranked by male colleagues. In 18 out of 20 district health board areas, female specialists received less pay - up to $73,000 annually - than men doing the same job. In the country's public hospitals, there are 1200 more senior male doctors than female counterparts. Only 6.5 per cent (17 out of 259) of orthopaedic surgeons and 22 per cent (48 out of 210) of general surgeons, for example, are women. Meanwhile, more than one in three obstetricians and gynaecologists - doctors who specialise in women's health - are men.
Experts warn those gender inequities within the medical workforce are having concerning consequences for patient care. The Weekend Herald could find no formal, wide-scale research on this issue - which in itself, experts say, is alarming - but we spoke to 29 people, including female doctors, patients, researchers, union representatives, politicians and women's health advocacy groups. We also collected data from all 20 district health boards to build a comprehensive picture of female representation in the health sector. Because while gender bias is wrong in any workplace, in the health system, it can kill.
Interviewees pointed to areas like cardiac health, where women display different heart attack symptoms than men, for example, and medicine's general bias to a demographic "norm" of a fit, healthy, 70kg man. Lack of care available for endometriosis, postnatal depression, prolapse and cervical cancer are just some examples of crippling women's health conditions severely neglected for decades, with Māori and Pasifika women in the highest risk categories.
"Doctors predominantly get trained to identify the [heart attack] symptoms that only relate to men," said one Nelson DHB specialist.
Female patients found it harder to be heard, she said. "If they go to a doctor with a problem, they are more likely to be told, 'you are depressed, you're overweight, it's your hormones' and less likely to have investigations that show there is a clinical problem."
Wānaka-based somatic sexologist Sonia Waters said often male doctors didn't know how to talk about the pelvis and had their own prejudices, which could create traumatic experiences for those female patients.
"The consequences of that are, women shut up and don't talk about it, and suffer."
The majority of female doctors spoke to the Weekend Herald on the condition of anonymity - they feared they could lose their jobs for speaking out against what they see as a "boys' club culture".
The Weekend Herald began investigating gender bias in our health system more than a year ago, after sharing a tragic story of a 28-year-old woman who was told for nearly a decade her serious illness was in her head.
She was prescribed antipsychotic medication and told, by mostly male doctors, to "deal with [her] anxiety" and that she was a "hypochondriac".
Turns out, it was in her head but not in the way doctors implied. She had a potentially deadly tumour in her brain. She survived - and her story sparked outrage. Dozens of women emailed in to share similar stories of being ignored or overlooked. Why do so many women feel like this?
One advocacy group, the Gender Justice Collective (GJC) backed by nearly 3000 Kiwi patients, doctors and academics, has been petitioning the Government for an overhaul of women's health services amid fears females are being significantly undervalued by our country's health system.
"Too many women are dying in New Zealand because there's no national strategy for women's health like there is overseas ... despite the problem affecting 52 per cent of the population it isn't being prioritised ... I do think it's sexism," Angela Meyer, the founder of the advocacy group, said.
Australia, Canada and the United Kingdom all have a national strategy for women's health - but New Zealand remains without one.
In the past year, health experts have repeatedly told the Weekend Herald the gender bias female patients experience is a ripple effect from a "boys' club culture" deeply ingrained within our medical workforce.
"It is absolutely crucial women feel heard and our health workforce mirrors the community it serves," top Australian public health physician and health law academic Dr Marie Bismark said.
At least one DHB has been confronted by senior doctors concerned about "undesirable gender inequality" problems in their workplace.
In October 2019, a group of senior doctors raised serious concerns with bosses at MidCentral District Health Board. The Palmerston North-based team said it had noticed worrying inconsistencies among the gender composition of the DHB's workforce - particularly as staff climbed the ranks.
Concerned, the leadership team launched a research project. It revealed that while a high number of women were entering New Zealand's medical workforce, there was a "significant decline" in those transitioning to senior positions. A report, produced in February last year, found the trend extended to the DHB's upper management.
Figures subsequently obtained by the Herald, showed a 70:30 per cent split in favour of males in senior doctor, medical leadership and clinical executive roles at the DHB - indicating a "strong visual impression of gender inequality", according to the report's authors. In addition, the report stated female doctors were less engaged and more likely to report being bullied. The findings suggested the DHB had "not actively pursued gender equality practices in at least five years".
In an action plan released in March last year, DHB bosses set key deadlines to assess and reduce gender imbalances, including but not limited to pay equity issues.
It was described as a "long term commitment ... intended to create immediate direction in a critical area of concern, which would help create a healthy culture that was more inclusive and positive for staff".
However, more than a year on, little progress has been made and the plan appears to have slipped off the DHB's priority list.
Meanwhile, data released under the Official Information Act shows alarming gender disparity trends at all public hospitals in New Zealand.
Not only are female doctors earning far less than their male counterparts, but there are multiple barriers for women to progress in medicine - including assumed domestic responsibility, ingrained sexist attitudes and unconscious gender bias.
Voices of female doctors
Dr X was still. She couldn't move, she couldn't sleep and she couldn't eat.
She was suicidal after repeatedly being told by district health board management her burnout was a "personality" problem and to suck it up.
Despite dedicating 20 years to being a physician, helping to save thousands of lives while missing special milestones with her kids, her voice continued to go unheard by management.
Sexism in medicine is a problem, she says. "Concerns of mine are minimised because I'm a woman, because I work part-time to try and manage my workload, and my family life. I hear I'm not a proper doctor because I don't work full time".
Jane (not her real name) gets shivers speaking about male surgeons asking female junior doctors for sex in order to progress their career.
It's 20 years since she heard those whispers but, she says, the ripple effects of those stories still linger.
"It's part of this ingrained and often hidden boys' club culture ... I think it can put women off progressing their career," the top clinical leader at one of New Zealand's biggest hospitals said.
Women who expressed strong opinions or who got visibly upset at work being labelled "hormonal" or "aggressive", Jane says.
"No one would ever say that about a male."
Savannah (not her real name) could hear herself speak but those around her failed to respond.
It's an out-of-body experience - one the senior female doctor says she experiences at nearly every department meeting.
Two minutes later, a pale male colleague echoes her comments. In an instant 20 heads turn his way.
"Great idea," one doctor said, and another repeated.
Savannah said gender bias was much worse in New Zealand than in the UK, where she previously worked.
"It's almost normalised here and it's not okay.
"Senior leadership roles go to people with the 'right attitude', meaning someone who thinks the same and has the same mental model of the world as a white, middle-class male"
A boys' club culture
Charlotte Chambers, principal analyst at senior doctors' union Association of Salaried Medical Specialists (ASMS), said it was a huge concern that a "boys' club culture" was preventing women from specialities they could be excelling in.
A 2019 report authored by Chambers, titled "Making up for being female", included anecdotes from 12 New Zealand senior doctors about gender bias they'd experienced working in medicine.
One doctor said in her department surgeons often picked the anaesthetist they played golf with at the weekend. She couldn't play because she was looking after the kids. Another female doctor said her male boss organised a 7am meeting, which she was unable to attend because she had to drop her children at school.
Australian paediatrician Dr Chloe Baxter conducted a survey, involving 500 New Zealand and Australian doctors, and found 20 per cent of participants were asked inappropriate questions about marriage and babies during their selection interviews.
While acknowledging the overall recruitment process had been conducted well, the apparent gender bias was concerning, she said during a webinar in November.
"My personal experience was that when I was pregnant I was told I should resign," Baxter said.
Meanwhile, as far back as 2015, a report by the Royal Australasian College of Surgeons, which oversees surgeons in Australia and New Zealand, found that nearly 50 per cent of all graduates reported being subject to discrimination, bullying or sexual harassment.
Bismark, the public health physician and health law academic, said there was significant gender inequity in surgery where inappropriate behaviour was rarely "called out", and instances of sexual harassment, and sexism more broadly, was commonplace.
Though there had been some improvement since that report was published, a lot still hadn't changed, she said.
The report recommended workplaces increased the appeal of surgery to more diverse groups, including women, by providing workplace and training flexibility, as well as setting targets for the number of women on training boards and college leadership roles.
However, nearly all DHBs remain without any plan to tackle the problem and one DHB, Nelson Marlborough, told the Herald: "We are not aware of any issues relating to gender equality with this workforce."
Advocacy groups hoped discrepancies between regions would be ironed out with the overhaul of DHBs and the introduction of the national health body due to take effect in July next year.
For now, the DHB's focus remains solely on addressing the gender pay gap.
Across all industries, the gap between Kiwi men's and women's hourly pay sits at about 9.5 per cent, according to Stats NZ figures. In specialised medicine, it's 12.5 per cent. That means while, overall, women get paid 91c to every $1 a man earns, in specialised medicine, it's 88c to $1. A 2019 report showed the gap in medicine widens to 14 per cent for those with one child and 17 per cent for those with two or more children.
Union investigates gender bias in senior doctors' pay
Gender pay discrepancy and concerns about ongoing bias have caught the attention of the country's senior doctors union.
ASMS is investigating the drivers behind the gender pay gap at hospitals in a bid to quantify the scale of the problem.
A pilot, involving three DHBs, is auditing medical specialists' remuneration and analysing the salary scale each doctor started on, the qualifications they had when they began, along with any additional remuneration and where they now sit on the salary scale.
The union aims to roll the programme out nationally by the end of the year.
"We are trying to get objective quantifiable indicators of qualifications etc...and on that basis, we will be looking to find out if there are gender differences, how did they manifest and what could be the reasons for those differences," Chambers, who is leading the investigation, said.
But she stressed the gender pay gap was just a small part of a much bigger problem.
"All DHBs have given us acknowledgement that gender equality is an issue of concern and they have all signalled their intent to fix it."
What needs to change?
With the problem ingrained over decades, there is unlikely to be any quick fix.
However, there are steps that can be taken to ensure women's health is no longer neglected - GJC is calling for an urgent select committee process, for the Government to set aside $6 million to overhaul women's health services and for a women's health and wellbeing strategy.
And to help tilt the scales in the medical workforce, experts say an urgent nationwide action plan is needed to tackle gender equality beyond just looking at pay gaps.
This would include encouraging flexible hours and shift-sharing, particularly after maternity, so having children doesn't "put a pin in a woman's career".
DHBs should introduce a scheme where parents, male or female, who wish to attend conferences could claim childcare expenses so they're not shut out of career development opportunities.
Open discussion and acknowledgement of gender equality were needed at every level of DHBs if there was to be meaningful progress.
Back at MidCentral DHB bosses have lifted the lid on their own organisation and acknowledged they have a gender inequality problem, but it has yet to implement its plan fully - citing Covid-19 for delays.
The DHB's chief medical officer Kelvin Billinghurst said several working groups had been established comprising clinicians, human resources and other staff. They were working on a pay gap analysis with reporting mechanisms, a flexible working arrangement, improving recruitment practices and providing mentoring to help female doctors progress.
Objectives included: gender balance across all levels of leadership, equal pay principles, support for the "unique challenges" faced by women in medicine, resources to help advance their careers and unbiased and objective people decision-making processes.
"It is highly complex but we are happy to be making the effort to seriously look through the issues and address where legitimate issues are raised," Billinghurst said.
The DHB acknowledged that gender diversity problems reflected generational "paradigms". But new policies could influence change, "to move away from untested assumptions that create barriers within our work environment and towards establishing a positive, productive, happy and healthy culture".
Chambers credited the organisation for identifying the steps it needed to take to ensure more women progressed to senior roles and received equitable salaries comparable to their male colleagues.
The plan was a "step in the right direction", she said.
Meanwhile, doctors like Lim, who trained for seven years within the DHB system, were leaving because "being an ethnic young woman [she] had no mana there".
"I want to create real positive change".