Abstract
Children’s books provide enjoyment and education, informing children’s understanding of the world and their place in it. Books about going to the doctor are used both for entertainment and to help prepare children for forthcoming clinical encounters. While the image of physicians in adult literature has attracted extensive review, 1 there has been relatively little scrutiny of children’s medicine-related literature, apart from one small study of the appropriateness of doctors’ attire, activities and personality. 2
Over the past few decades, the number of female doctors in the UK has increased steadily, and now over 50% of UK medical students are female. 3 We were interested to see whether and how this might be reflected in children’s medicine-related literature. To explore this, we collected illustrated fictional and factual books that address medical consultations and hospitalisation and had been written for pre-school children and those in primary education (ages 4–11). We looked for books in the public library, second-hand bookshops, on-line booksellers, the local children’s hospital and the specialist teaching collection of the University of Brighton. In addition, publishers kindly sent us soon to be published books. We confined our critique to books published since 2000 as we considered that these books were more likely to be bought or borrowed and could be expected to reflect current realities in the medical workplace.
Reviewing both the text and illustrations of 48 books, we were able to identify 145 discrete doctor–patient encounters. Only 37% of the doctor characters were female and 59% were male. There was also a gender imbalance among the patients with only 32% being female (Figure 1). There were a small number of doctors and patients where it was difficult to assign a gender, as they were played by animals of indeterminate sex. Arguably, from a feminist perspective some ambiguity or androgyny in the representation of doctors’ gender is a desirable objective.
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The books reviewed portrayed gender imbalance, there were more male doctors and more male patients represented than females (Source: Page from Usborne First Experiences: Going to the Hospital by Anne Civardi and illustrated by Stephen Cartwright, Usborne Publishing Ltd, London, © 2005 Usborne Publishing Ltd).
Work force statistics tell us 37% of GP partners and one-third of hospital consultants are female
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but the children’s books we reviewed did not reflect this reality; 70% of the female doctors were portrayed working in primary care or a community setting and 30% in hospital, while the male doctors were evenly divided between primary and secondary care (Figure 2). The tendency to show women in primary care could be interpreted as stereotyping with women placed nearer the home and further from the high status world of hospitals. Female doctors were more likely to be portrayed taking a history from their patients, while their male counterparts were more likely to be portrayed undertaking examinations or procedures. To the child impressed by diagnostic technology, the work of the male doctor may appear more important. However, in reality, doctors still remain heavily reliant on history in non-urgent scenarios,
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and the relative time spent in clinical practice taking a history confirms its primacy in diagnostic problem solving.
Female doctors were represented as younger than their male colleagues (Source: Page from My Visit to the Doctor by Susan Hitches and illustrated by Priscilla Lamont, Egmont Children's Books Ltd, London, © 2001 Egmont Children's Books Ltd).
In so far as we could ascertain, the female doctors appeared to be younger than their male colleagues. This is based on our subjective estimates of age in 10-year bands, as judged by their physical appearance in illustrations (p < 0.001). This could be an accurate reflection of the changing demographics of the medical workforce, with an increasing proportion of female graduates in recent years. Alternatively, it could be interpreted as a traditional view of the roles and hierarchies within medicine.
The majority (60%) of the books reviewed were authored by women, while men authored 24%. In the remaining 16%, it was either impossible to assign gender on the basis of the available information or there were male and female co-authors. There was a trend for an increased proportion of recently published books to have been authored by women. Interestingly, female authors were less likely to write humorous books or create animal characters and they rarely portrayed doctors with negative characteristics or poor clinical practice.
We were interested to see whether the author’s gender influenced the choice of gender of the doctor characters they created. We found that female authors created an equal number of male and female doctors, while most of the doctors created by male authors were male. Where an illustrator or photographer was involved in book production there was no relationship between their gender and the gender of the doctor character they portrayed or photographed.
While most of the books expressed positive aspects of the doctor–patient encounter, a number of negative behaviours were also evident. These included such poor professional practice as refusing to see patients, brusque or hurried manner, breaching confidentiality and treating their own children. One story involving animal characters showed the doctor refusing to see animals of a different species. We were pleased to note that as the story progressed he learned that such discrimination was unacceptable and his professional behaviour improved. Reassuringly within the books we reviewed, there was no relationship between the doctor’s gender and whether they were portrayed as friendly, compliant with infection control practices or adherent to good medical practice as defined by the General Medical Council. 7
In conclusion, our review of children’s medical-related books has revealed a gender imbalance with women underrepresented both as doctors and as patients. You may ask does this matter? We suggest it does, because young children lack autonomy and, as they do not have editorial control, it is important that they have access to books that reflect social reality. On the other hand, we acknowledge that books are just one of many influences on the construction of gender models: others, particularly children’s television programmes, are far more important. 8 Our purpose is not to label books as good or bad, but to heighten awareness of the current mismatch between representation, reality and aspiration. Perhaps we can also enthuse those readers of the JRSM with literary skills to consider remedying this mismatch?