The Shifting of Gender in Dentistry
Dominic Saadi, MA
In nearly every aspect of modern life in America—educational, personal, professional—both the advantages and disadvantages of being either a man or a woman are carefully broken down and scrutinized. Are boys really better than girls at math and science? Are girls more artistic than boys? Are women better multi-taskers? Are men better entrepreneurs? Can women be good corporate executives, and can men really be good stay-at-home dads? Why is women’s average life expectancy higher than men’s?
The real question seems to be: Is it the biology of the sexes, or the sociology of the genders, that really matters?
What role do these questions play in dentistry? More specifically, what is the true nature of changing gender demographics and the impact of women on dentistry in the United States?
Traditionally, the study of women’s health was limited primarily to the reproductive system. Otherwise, men were considered the biological norm for medical evaluations and clinical studies that were applied to both sexes. The standard male model was unable to explain, without specious anecdotes, the fact that women’s life expectancy exceeds men consistently across ethnic groups, or that disease and drugs affect the sexes differently.
Beyond the anatomically obvious reasons that only men contract prostate cancer and women ovarian cancer, scientists are now looking to further explore the basic genetic and physiological differences between the sexes regarding health and patterns of illness across the lifespan.1 It has been only within the last 20 years that an appreciation of gender-based differences has gone beyond the reproductive and hormonal to the basic cellular, molecular, and genetic levels. Consciousness of the variability of health and disease between the sexes has led to the mobilization of resources to provide experimental evidence thereto and to the translation of the scientific information on gender differences into preventive, diagnostic, and therapeutic practice.1 To specifically address women’s health issues and health-related careers, grassroots initiatives and public policy ultimately resulted in the following achievements:
• In 1991 the National Institute of Health established the Office of Research on Women’s Health (ORWH) to support the advancement of women in health research and health careers. Its funding policy requires the inclusion of women and minorities in all of its research studies.
• The Federal Glass Ceiling Commission was created by the Civil Rights Act of 1991 to identify and eliminate barriers obstructing the career advancement of women and minorities.
• The Commission on Graduate Medical Education (COGME) addresses women’s health issues and has made recommendations such as a multidisciplinary approach to women’s health, and the recruitment and promotion of women in health leadership positions.2
An enumeration of the salient objectives delineated over the course of the three American Dental Education Association’s (ADEA) International Women’s Leadership Conferences demonstrates the integral role that women are playing to improve dental and systemic health and to encourage the advancement of women in dentistry, including:
• global issues in dental and oral health related to systemic health;
• the advancement of women in academic and research careers and in professional societies;
• mentoring, role-modeling, and networking;
• the clinical relevance of gender and oral health (including the women’s HIV study);
• the gender/generation gap—women as change agents for organizational change;
• work-related issues—time management and leadership in the office;
• entry to dentistry through different career pathways;
• alternative medicine and women’s health, and keeping women fit; and
• reentry—engineering career development and management.3
With the above agenda, government programs, together with private associations, such as the American Dental Association (ADA) and ADEA, have made a positive difference in the study of women’s health and the advancement of their careers in the health sciences. The cornerstone of the ADEA’s programs fostering the advancement of women in academic dentistry is the Center for Equity and Diversity under the sagacious leadership of Dr. Jeanne C. Sinkford. Other ADEA initiatives supporting women’s advancement are:
• The Scholars Program;
• Women Liaison Officers;
• Women’s Health Information Network;
• ADEA’s Annual Session;
• Hedwig van Ameringen Executive Leadership in Academic Medicine; and
• ADEA Leadership Programs.2
Nowhere are the effects of these programs more manifest than in the changing demographics of women in dentistry.
THE CHANGING FACE OF DENTISTRY
To say that women had a slow start in dentistry would be a generous understatement. Before 1970, the number of women in dentistry in the United States was virtually nil; it was the lowest percentage in the Western world. Roughly half of the dentists in Greece at that time were women, and women made up about one third of the dentists in France, Denmark, Sweden, and Norway and almost four fifths in Russia, Finland, Latvia, and Lithuania.4
Dentistry in the United States, like all professions and corporations, as well as the government and the military, once was a male preserve. Even today, women are still greatly underrepresented in the physical sciences, engineering, and technology fields.
Women were victims of stereotypes and hostile attitudes characterizing them as emotional, undependable, distracting, flighty, lacking in physical strength, undesirable because they are likely to get pregnant, and somehow less capable than men of practicing dentistry.5
But then things changed. The civil rights movement of the 1960s stimulated the women’s movement along with minority causes and galvanized grassroots activism and public support, resulting ultimately in a gender sea change. Up until the early 1970s, women entering dental school accounted for a meager 1% to 2 % of the total. A watershed year for women was 1975, which was designated "International Year of the Woman." That same year saw Time magazine celebrate the achievements of 12 American women in its cover story, "Women of the Year," exhorting women’s equal social and professional rights."2 This was the start of federal policies to fund grants and encourage increasing enrollments of women and minorities in professional health schools.5 The results are impressive; by the mid-1980s female dental school entrants comprised 19.8% of the total. By 1990 the number rose to 38%, and as recently as 2005, it was up to 44%. The percentage of female dental school graduates in 2006 was 44.9% of the total, and the total enrollment by gender was 44.3% female and 55.7% male.6
As dental schools head toward a 50% male/female ratio, and indeed some East Coast schools are already there (New Jersey’s Science & Technology University is at 55% women), will female faculty and administrators catch up proportionately to the number of female students? The emphasis and growing success of role-modeling and mentoring in career and leader-ship development cannot be overstated.3 Currently women constitute 28% of dental faculties, 22% of deans, and 31% of total academic administrators—a world away from 1975 when Dr. Sinkford was the first and only dean of a dental school in the United States. Today 13 of 57 dental school deans in the United States are women. The year 1991 saw Geraldine Morrow, DMD, become the first female president of the ADA.
Estimates are optimistic for women to reach parity with men faculty and administrators in the next generation as the increase in female dental graduates will be reflected in proportionate representation of women in leadership positions. To that end, women’s leadership training is driven by programs such as the ADEA Leadership Programs and Executive Leadership in Academic Medicine (ELAM), which can boast of graduating three current deans, according to Dr. Sinkford.
The percentage of active private practitioners, 18% female to 82% male, and the percentage of new active private practitioners, 34.7% to 65.3%, respectively,7 reflects the steady increase of female dental students over the last generation; within the next generation female practitioners should reach numerical parity with their male counterparts.
These are impressive numbers. Women have come a long way in bridging the gender gap in dentistry. But has gender parity erased gender differences? To what extent do estrogen and testosterone determine behavior patterns and brain functions for women and men respectively? Are men and women essentially different? Are women more articulate, verbal, compassionate, em-pathetic, sensitive, cooperative, sentimental, and loving? Are men more competitive, risk-taking, assertive, aggressive, independent, analytical, and self-reliant?
The most cursory examination of contemporary American society should dissolve any notions of fixed gender stereo-types, as women and men work outside the house at a roughly equal rate, and share housework, shopping, and child-rearing responsibilities. The eradication of the old boundaries separating the worlds of men and women coupled with the increasing sharing of home and work functions forms a behavior and lifestyle pattern that sociologists Molly M. Lang and Barbara J. Risman call "gender convergence."8 Gender convergence applies not only to the soft topic of the mutual sharing of work, but extends to women doing what have been traditionally "men’s jobs": protecting the public as police officers and firefighters, defending the country by serving in the military, and exploring the great unknown by piloting space shuttles. The ineluctable inference to be drawn from these observations is that the abiding differences in behavior and consciousness between men and women are less innate than a result of circumstances and politics.
Yet, because women can do just about anything that men can do, and because the differences between them have narrowed considerably, it is not to say that differences do not exist. This article has already sketched genetic-based and physiological differences between men and women. What about social and cultural differences? Do they still exist even as the adamantine walls of patriarchy are coming down? Look at the socialization process. The fact that women bear and nurse children and are still the primary caregivers through old age, a kind of womb-to-tomb nurturing career, makes a significant difference in the personal nurturing disposition of women. Notwithstanding gender-convergence and the greater role that men play in the household and women outside of it, it is still women who give more time, attention, and care to children and the aged right through the lifespan of the family. As primary caregivers, women tend to elevate family health standards by educating the family about health and preventive care. Studies have shown that the level of healthcare and knowledge in families is directly related to the education of the caregiver, Dr. Sinkford says. Outside the home, the vast majority of healthcare workers remain women.
Furthermore, women’s special talents are not restricted to the world of sympathy and compassion. Their acute sensitivity about human feelings and the needs of others—empathy—predisposes them to a unique perspective of science. For example, Barbara McClintock’s uncommon insights in genetics won her the Nobel Prize for discovering "that genes can rearrange themselves on a chromosome. The direction of her research was informed by a ‘feeling for the organism.’"9 Jane Goodall and Dian Fossey, pioneers in the study of primate behavior, did not follow the traditional science procedure of hypothesis followed by corroborative evidence, but instead "took a relational approach and focused on a single ape, tracing that primate’s interactions," and thus established a paradigm for the study of wildlife.9 The perceptions and methods of these women were unique, a product of gender socialization, as their seminal scientific discoveries were a result of intuitive perceptions, built on feelings and relationships.9
A WOMAN’S TOUCH
The foregoing raises an interesting question: do women have something of significance to teach precisely because of the way they learn and appropriate reality, and does that conflict with the traditional male model with its aggressive, competitive, and analytical ethos?9 Is the male-dominated paradigm in dentistry in trou-ble? Hardly, but its hierarchical command and control methods of education and practice are coming under increasing, albeit incremental, reform amid the women’s health agenda and the growing num-ber of women in school, practice, and leadership positions.10
The challenge of changing the dental curriculum (with its narrow focus on science and techniques) to better respond to the needs and talents of a diverse and pluralistic society has been undertaken by the various government and private programs described here. The result is that the dental school admissions process and curriculum have become more sensitive to women’s health differences, as well as to gender and minority equality. Criteria have expanded to encompass a more diverse student population. Admissions at an increasing number of dental schools now include "whole file review," which evaluates the whole person beyond just academic grades, giving due weight to the "road traveled" (ie, socio-economic background, non-cognitive abilities, community service, work, etc), Dr. Sinkford explains.
This does not mean that standards have been lowered to accommodate women, who, to the surprise of some unregenerated sexists, are outperforming men on average in school as well as on national board scores, such as the SAT Reasoning Test and DAT (Dental Admission Test). What it does signify is the growing awareness that the dental landscape is enriched by the fertilization of diverse and valuable contributions of women and minorities mixing in their own unique perspectives and talents. The gender change in student, staff, and leadership is gradually moving toward reorienting dentistry from its "focus on diagnosis and treatment to a ‘more humanistic’ approach to healthcare, including greater emphasis on primary prevention and health promotion."10
We have seen how biology and culture equip women in a unique way to integrate hard science with the nurturing arts. The pedigree of women as healers goes back to the dawn of history, leading right up through their roles as midwives, nurses, and hygienists. In fact, dental hygiene, the very basis of prevention, was born with women and continues to be dominated by them. They add a personal component to their relationship with patients as they educate them about preventive care and the nexus between oral and systemic health.
Yet, notwithstanding the critical and indispensable importance of hygienists and nurses, the doors to the upper levels of the medical and scientific professions were blocked by the patriarchical gatekeepers early in the 20th century, and not opened until the last quarter of that century, and only under considerable pressure from women’s groups and government agencies. Since then, however, the numerical progress of women in all aspects of dentistry has been striking.
In marking the growing numbers, influence, and unique value of women in dentistry, there is a climactic question: what is the quality of their impact? Do women add more than just a quantitative component by increasing the competitive pool? Do they make dentistry better? Are their unique talents sufficiently appreciated and optimally exploited? To what degree have they changed dentistry and to what degree have they been changed by dentistry? All provocative and tantalizing hypothetical questions for which there are mostly tentative and varying answers as information is preponderantly anecdotal.
The discussion of these questions will revolve around the business and the profession of dentistry. Female dentists unanimously agree on the joys of dentistry for providing not only professional status and revenue, but a flexible schedule tailor-made for family needs. Because of pregnancies and family considerations, women tend to join group practices rather than own a separate practice, which happens to dovetail with the national trend toward group practices, as they are more efficient and capitalize on economies of scale. Women put in the same or more hours than men by working more days and hours to compensate for family obligations and also working longer careers as they outlive men. Women’s associations, networking, and role-modeling are paying dividends as women are participating and contributing equitably at all levels of dentistry.
Just as the business of dentistry is kind to women, women are kind to the business of dentistry as well. As Dr. Sinkford observes, "enhanced office esthetics are a welcomed contribution by women to what was once a rather foreboding and austere dental theater, scaring the wits out of a fair number of unsuspecting, innocent children."
Children and women often favor female dentists. Dr. Lynn Carlisle attests from personal experience (because his first name is Lynn) that women often schedule appointments with him precisely because they think he is a woman. One of the reasons he adduces for this is the perception that women are more gentle and caring; the other is women supporting women.11 Women spend more time with patients, and minority women do more pro bono work than others because they do more with disadvantaged and poor patients.7 The anecdotal is supported by data, as numerous studies show healthcare outcomes improve with a good doctor-patient relationship.11
Notwithstanding all of the above—wom-en’s equitable representation and special contributions in dentistry—the traditional business model remains pretty much intact, with "the emphasis on technology, techniques, risk management, science, cost efficiency, and the shifting requirements of insurance companies and employers...," with the net result of prejudicing a healthy doctor-patient relationship.11
What is true of the business model of dentistry is no less true of dentistry as a whole—the way it is taught and the way it is practiced. The "scientific" model still reigns, despite some reforms and a growing consciousness of holistic health and the needs and interests of a diverse population. Even though, as noted above, dental schools have changed admissions criteria to recruit and cultivate more women and minorities, they still have not moved away from the hierarchical, scientific paradigm toward a more humanistic, holistic, and wellness approach that incorporates science and treatment as an equal—not hegemonic—component among other promising therapies.
The conclusions Dr. Carlisle has extracted from "relationship-based dentistry" seminars and forums agree largely with the author’s findings: Women have some social and biological relationship advantages, but the selection and training process in dental schools tends to negate this advantage. This selection and training process favors people with analytical, deductive aptitudes in science, engineering, tactics, and techniques, as well as a "thing" instead of a "people" orientation.11
But there is hope for a renewed dentistry dawn with the work of people like Dr. Carlisle and Dr. Sinkford despite the inertia of a century of hierarchical, male-dominated dentistry. While much remains to be done, appreciable progress is being made as some dentists are performing relationship-based dentistry and oral/systemic medicine with a focus on health and wellness instead of disease. The theoretical foundations for a paradigm shift are in place. The call for a more relationship-based, health-centered dentistry that includes the nurturing voice of women is loud and clear—its time has come.
References1. Exploring the biological contributions to human health: does sex matter? Washington, DC: Institute of Medicine, National Academies of Science. 2001;1-2.
2. Sinkford JC, Valachovic RW, Harrison S. Advancement of women in dental education: trends and strategies. J Dent Educ. 2003;67(1):79-83.
3. Sinkford JC. Global health through women’s leadership: introduction to the conference proceedings. J Dent Educ. 2006;70(11 suppl): 5-7.
4. Health Professions—Dentistry. Washington University School of Medicine. 2004;1.
5. Neidle E. President’s address. J Dent Educ. 1986;50(7): 380-382.
6. American Dental Association. Division of Education. 2006.
7. American Dental Association. Survey Center. 2004.
8. Lang MM, Risman BJ. Council on Contemporary Families. A "Stalled" Revolution or a Still-Unfolding One? The Continuing Convergence of Men’s and Women’s Roles. A Discussion Paper prepared for the 10th Anniversary Conference of the Council on Contemporary Families, May 4-5, 2007, University of Chicago.
9. Pollina A. Gender balance: lessons from girls in science and mathematics. Educational Leadership. 1995;53(1):30-33.
10. Blanton P. Women in dentistry: Negotiating the move to leadership. J Dent Educ. 2006;70(11 suppl):38-40.
11. Carlisle LD. Is there a difference in the way men and women practice dentistry? Part II. In A Spirit of Caring. Available at: www.spiritofcaring.com/public/513.cfm. Accessed on September 20, 2007.