Abstract
Prior studies note that gender- and race-based discrimination routinely inhibit women’s advancement in medical fields. Yet few studies have examined how gendered displays of deference and demeanor are interpreted by college-educated and professional Latinas/os who are making inroads into prestigious and masculinized nontraditional fields such as medicine. In this article, we elucidate how gender shapes perceptions of authority and competence among the same pan-ethnic group, and we use deference and demeanor as an analytical tool to examine these processes. Our analysis underscores three main points of difference: (1) gendered cultural taxation; (2) microaggressions from women nurses and staff and; (3) the questioning of authority and competence to elucidate how gendered racism manifests for Latina/o doctors. Taking demonstrations of gendered deference and demeanors are vital to transforming medical schools and creating more inclusive spaces for all physicians and patients. Conclusions are based on experiences reported in interviews with 48 Latina/o physicians and observation in their places of work in Southern California.
Gender is a critical mechanism that stratifies men and women among both culturally perceived feminized and masculinized professions (Bhatt 2013; Cassell 1998; Lorber 1984; Murti 2012; Williams 1992; Wingfield and Chávez 2020). Today, Latinas/os 1 are the largest racial/ethnic minority group in the United States, and a small but growing number of Latinas/os are making inroads into prestigious nontraditional careers in STEM (science, technology, engineering, and mathematics) fields such as medicine. 2 However, few studies have examined how gender-based discrimination produces markedly different experiences for college-educated Latina/o physicians who work in the same masculinized occupation. Using Goffman’s (1956) ideas of deference and demeanor, we elucidate how gendered displays of deference and demeanor, or lack thereof, can constitute one of the mechanisms that shapes the educational and professional experiences of Latina and Latino doctors.
All organizations have inequality regimes that serve to maintain and replicate larger patterns of gender and racial inequality (Acker 2006; García-López and Segura 2008; Wingfield 2019; Wingfield and Chávez 2020). This is especially the case in the STEM fields that have a distinctly white, hetero-masculine culture (Alfrey and Twine 2017; Ong 2005), creating challenges for those who deviate from that description. Ong (2005, 598) notes that “to claim membership in science women of color must maintain the appearance of belonging to a culture of no culture.” For women of darker phenotypes, corporeal appearances stand at odds with the identity of STEM professionals, resulting in their engaging in daily impression management strategies (Alfrey and Twine 2017; Goffman 1956; Ong 2005) to communicate their expertise and competence in science. This comes with personal costs, such as compromising one’s identity by concealing cultural differences in an attempt to fit into the mold of a scientist.
Although doctors occupy a higher position in the organizational structure than nurses and staff, hierarchies persist within and across this occupational grouping. Goffman (1956) notes that displays of deference and demeanor accentuate the inherent status differentials embedded in medicine. Goffman (1956, 476) writes that “doctors give medical orders to nurses, but nurses do not give medical orders to doctors . . . in some hospitals in America nurses stand up when a doctor enters the room, but doctors do not ordinarily stand up when nurses enter the room.” For instance, as white women entered the medical profession, they were initially gender-typed into less lucrative specialties and snubbed by some white men doctors and nurses (Cassell 1998; Lorber 1984). Despite occupational status distinctions, both Black physicians and nurses are subject to racial outsourcing (Wingfield 2019), performing additional job tasks not asked of white counterparts when serving racial- or language-minority populations. Thus, navigating this tightrope can be distinct for nonwhite physicians, who must carefully tread interactions with coworkers and patients of various social locations.
While there is an occupational hierarchy in the medical field, a gendered hierarchy intersectionally is also present. Murti (2012) and Bhatt (2013) explain that gender, race, and nativity status in the United States combine to produce unequal experiences for South Asian men and women physicians, with South Asian men more able to deflect discrimination by revealing their occupational status. These dynamics are raced and gendered, as Kwon and Adams (2018) show that Asian Canadian women doctors in training were subject to hostility from nurses. Moreover, Latinas pursuing medicine note the unique stressors they face because of gendered cultural expectations from their families and patients (Flores 2019; Grijalva and Coombs 1997). Although Wingfield and Chávez (2020) find that Black doctors—both men and women—describe structural discrimination across multiple organizations more often than individual acts of discrimination from nurses and staff, Latinas pursuing medicine note that ethnic stereotypes result in unreasonable expectations where they are judged by harsher standards (Grijalva and Coombs 1997). Latinas traverse racial and gendered stereotypes while pursuing medicine, but little is known about how these dynamics translate to gendered displays of deference and demeanor in their workplaces as physicians.
This study addresses this lacuna by finding answers to the following research questions: How does gender shape perceptions of authority and competence for Latina/o doctors? And what role does self-presentation play? Through in-depth interviews with 48 Latina/o physicians and 30 hours of ethnographic observation in medical facilities in California, we elucidate how demonstrations of deference and demeanor intersect with gender stereotyping to produce distinct experiences for men and women doctors among the same pan-ethnic group. By considering how deference and demeanor operate based on multiple intersecting factors, and centering our focus on Latina/o physicians who have historically been marginalized from US medicine, we use our findings to illuminate how these processes disproportionately result in unequal outcomes for Latina physicians. We argue that taking gendered deference into account in the unique work lives of Latina/o physicians can create more inclusive spaces for them across various institutions.
In what follows, we provide an overview of current research that explains intersectionalities in STEM fields and also discuss how gendered displays of deference and demeanor, or lack thereof, shape how gendered racism manifests in the educational and professional trajectories of Latina/o doctors.
Literature Review
Intersectionalities in STEM
Men and women experience the world of work quite differently in both culturally perceived feminized and masculinized STEM fields (Bhatt 2013; Cassell 1998; Kwon and Adams 2018; Lorber 1984; Murti 2012; Wingfield and Chávez 2020). Cultural beliefs about gender serve as the foundation for discrimination against women in white-collar and STEM-related organizations (Cassell 1998; Lorber 1984) and produce vastly different experiences for men and women who are part of the same racial/ethnic category (Bhatt 2013; Britton 2017; Murti 2012; Pierce 1996). For example, white women faculty in STEM fields resisted descriptions of workplaces as “chilly” and minimized or denied gender’s importance in quotidian interactions (Britton 2017). To white women, gender mattered only when it intersected with organizational tasks such as service “housekeeping” and stereotypically gendered expectations of women being caretakers and nurturers. Thus, gender became heightened solely in unwelcome moments and receded just as quickly.
Nevertheless, as white women entered medicine, they soon found they were gender-typed into less lucrative and prestigious specialties (Cassell 1998; Lorber 1984). Although women were no longer subject to formal gender discrimination and could achieve better staff appointments, they encountered invisible barriers such as the glass ceiling, which inhibited their vertical mobility (Lorber 1984). Some established white men doctors treated co-racial women doctors as equals, but those who saw women as threatening competitors attempted to keep them subordinate (Cassell 1998). As Alegria (2019) notes, white women experience a “glass step stool,” only a small lift, instead of a glass escalator (Williams 1992) in technology work sectors. These studies emphasize that perceptions of gender discrimination vary; white women’s experiences are not universal, and generalizing white femininity to all women who work in masculine spaces stymies efforts to diversify STEM sectors.
Gender discrimination in STEM shifts depending on the social location of the group in question. For instance, South Asian women doctors face “social marginalization,” where they are rejected for their career status because they are perceived as undermining the authority and achievement of men (Murti 2012). Both Murti (2012) and Bhatt (2013) explain that gender, race, and nativity status intersect to produce unequal experiences for South Asian women and men physicians who work in the United States, with South Asian women doctors more likely to experience sanctions for being brown or foreign-born. However, when examining racial discrimination among Black doctors, Wingfield and Chávez (2020) note that Black men physicians narrate racism as an aberration and indicate that racial discrimination is more likely to be experienced by Black health personnel who hold positions in the lower echelons of the medical hierarchy. Thus, workers’ experiences with racial and gender discrimination derive from their position within the organizational structure (Wingfield and Chávez 2020) and may evolve over time and place (Hulko 2009).
Regardless of their position in organizational hierarchies, Black medical professionals experience racial outsourcing, where they perform uncompensated equity work to make organizations more accommodating to minority patients (Wingfield 2019). Minority professionals are also tasked with performing cultural competence and sensitivity when working with co-ethnics, an example of “cultural taxation” (Padilla 1994). This unremunerated knowledge is heavily gendered, and enacting this extra labor requires an analysis of the forms of self-presentation that racial/ethnic-minority professionals traverse.
Gender and Self-Presentation
Asymmetrical power relations can obfuscate gender and self-presentation rules of conduct in organizations (Cassell 1998; Goffman 1956; Ong 2005). Goffman (1956) explains two modes of presentation rules that conduct falls into: deference acts and demeanor acts. Deference acts encompass presentational and interpersonal rituals that specify what should be done and how recipients should be treated in interactions. They may be linguistic statements of praise or depreciation; gestural or spatial acts, such as preceding others through the door; or task-embedded acts. For example, Cassell (1998) finds that women nurses were deferential to older men surgeons, whereas white women surgeons were frequently questioned about their expertise and expected to modify their behavior in the operating room. White men surgeons could throw tantrums and complain, but tensions escalated when women exhibited this behavior (Cassell 1997). Nurses often acted as “enforcers of gender-appropriate behavior” (Cassell 1997, 50) and engaged in same-sex policing by helping men surgeons gown and glove before operations while women surgeons dressed themselves. Thus, nurses and coworkers perpetuated a discriminatory gender order.
However, these dynamics are fluid; Acker (2006) notes that all organizations have “inequality regimes” which serve to maintain class, gender, and racial hierarchies that are not always visible to all members of society. This is especially important when considering how interpersonal acts of deference and demeanor are demonstrated toward racial/ethnic minority professionals in STEM fields that are presumed to have no distinguishable organizational culture or identity (Ong 2005; Valian 1999). For women in science, elements of self-presentation include style and content of speech, posture, clothing, hair length, skin tone, age, and body shape (Ong 2005). Problems between social actors ensue when expectations over self-presentation clash. Such is the case in Kwon and Adams’s (2018) assessment of Asian-Canadian women medical professionals in training who were advised by white women colleagues to remain “humble” to avoid negative interactions with nurses, and Latinas pursuing medicine who experience sexually derogatory comments linked to ethnicity (Grijalva and Coombs 1997).
Demeanor, on the other hand, is an individual’s behavior displayed through actions or presentation of self. A well-mannered person has discretion and sincerity, modesty in claims regarding self, command of speech, and self-control over emotions and appetites. As Valian (1999, 15) explains, a “feminine woman runs the risk of seeming less competent; the more she typifies the schema for a woman, the less she matches the schema for the successful professional . . . a woman with masculine traits runs the risk of appearing unnatural and deviant.” Indeed, studies show that women who self-promote, act assertively, or dominate interactions are more negatively evaluated. Latina lawyers, for example, express dual femininities by subduing cultural aspects in their appearance to avoid being misidentified and racialized as service workers (García-López and Segura 2008).
Racist and sexist ideologies permeate the social structure and become hegemonic, suggesting to women that they need to relegate their cultural identities to the margins or manipulate their bodies to avoid prejudice for their appearance and demeanor. Femininity is often perceived as antithetical to a scientist’s identity, and women may attempt to embody masculine forms to gain respect. Interestingly, however, white women in technology were more likely to be promoted by their supervisors for their competence in interpersonal skills and were rewarded for embodying white femininity (Alfrey and Twine 2017). Gender-fluid Asian and white women were perceived as more competent by male colleagues and avoided microaggressions routine among conventionally feminine, heterosexual women (Alfrey and Twine 2017). These studies show how deference and demeanor are evaluated differently based on the intersection of multiple social categories and occupation type.
Methods and Research Description
This study draws from 48 face-to-face interviews with self-identified and currently practicing Latina/o physicians—22 men and 26 women—and 30 hours of ethnographic observation. Observations took place in physicians’ workplaces and medical galas/events geared toward fundraising scholarships for Latina/o students striving to attend medical programs. California is an ideal location to study Latina/o physicians because the state has more than 2,000 (about 5 percent) (Association of American Medical Colleges [AAMC] 2018).
To be eligible, participants had to self-identify as Latino (of any racial background) and be a currently practicing medical doctor or advanced intern. Participants in the study were transitioning out of a medical residency program, on a research fellowship, or were currently employed at a medical facility or research institution. The doctors were employed at hospitals, clinics, and medical groups in Southern California. Latina/o physicians were recruited by online search through medical center department websites; they were then contacted via e-mail (Bhatt 2013) with an institutional review board–approved script. This initial process led to snowball sampling, in which physicians referred their colleagues and members of their medical school cohorts. Snowball sampling produced seven additional women participants. In-depth interviews were conducted between 2014 and 2019.
The interviews took place at a time and location most convenient to participants: private offices, hospitals, clinics, school campuses, and cafés or eateries during their lunch break. The first author, the U.S.-born daughter of Mexican immigrants, is bilingual, allowing physicians to code switch during the interviews. In this case, gender and ethnicity facilitated access (Baca Zinn 2001): All Latina/o physicians were enthusiastic about recounting their pathways into the occupation and their experiences as professionals in a white-collar field where they are severely underrepresented.
The interview guide included 25 open-ended questions that covered pathways into medicine, specialty, and “matching” processes, as well as relationships with patients, colleagues, and coworkers. Interviews were conducted in person or on the telephone and audio recorded unless the respondent preferred not to be recorded. In only one case, the first author took extensive notes and jottings during the interview, which were later turned into an extensive memo. Telephone interviews took place at a time of the respondent’s preference and followed the same semi-structured format as face-to-face interviews. Member checking occurred during and at the end of the interview to increase the rigor of results. To protect participants’ confidentiality, we have masked or omitted personal details such as specialty where extraneous to understanding a theme or experience.
We used strategies for analyzing qualitative data by first transcribing audio-recorded interviews verbatim. All of the transcribed interviews were uploaded into MAXQDA, a qualitative coding software that allowed both co-authors to access transcribed interviews and place them into key themes. We shared a coding and analytical memo, in which both authors would indicate new codes that were added and how they were defined. We then conducted selective or focused coding and put their responses into key thematic categories. This iterative process increased intercoder agreement.
Sample
Table 1 shows the demographic characteristics of the men and women physicians included in the study. Of the 48 Latina/o physicians, the overwhelming majority of them (40 of 48) were of Mexican origin, the largest Latinx subgroup in the United States. Two were Central American, four were South American (Colombian, Peruvian, or Brazilian), and two were Puerto Rican. The physicians of South American origins, all foreign-born women, had parents who worked in white-collar occupations such as physicians, engineers, and lawyers in their home country. However, the overwhelming majority of Mexican origin physicians (39) had immigrant parents who worked in service or factory work. Women’s ages ranged from 29 to 62 years, and the average age was 41. Men’s ages ranged from 33 to 76 years, and the average age was 38. Eight of the physicians were finalizing their medical residency programs, evinced by their lower salaries, but were transitioning into higher-paid positions. The rest were working for community clinics or larger medical organizations. Nearly 60 percent of women worked in feminized specialties such as family medicine and pediatrics. In contrast, 48 percent of men worked in pediatrics or family medicine and the rest in more “masculine” fields. Nine Mexican American physicians were surgeons, with only two women in this category as an ophthalmologist and a cardiologist. The men worked as plastic, orthopedic, pediatric, general, or trauma surgeons. Except for two physicians who self-described as later generation and not Spanish proficient, all doctors stated they were bilingual. Men were more likely to claim fully bilingual capabilities, even though language facility was noticeably choppy during the interview. The average time in practice for women was 11 years, and for men 10 years. Men, on average, earned much higher salaries than their women counterparts, with one earning well over $600,000 a year and owning his own private practice. Five doctors declined to state income information.
Physicians’ Demographic Statistics by Sex
This category consists of participants who self-identified as Mexican, Mexican American, Chicana/o, and Xicano.
Four female participants and one male participant did not provide annual income information. The percentages are based on a total of 22 females and 21 males.
We relied on the narratives of Latina/o physicians to highlight how deference and demeanor are gendered and experienced differently by men and women of the same pan-ethnic background in a traditionally white, hetero-masculine field. We examine the interpersonal interactions that occur in the medical field and focus on three themes: (1) gendered cultural taxation; (2) microaggressions from women nurses and staff; and (3) the questioning of authority and competence to show how gendered racism manifests for Latina/o doctors. The data use an intra-Latina/o dynamics lens to demonstrate how displays of deference and demeanor are gendered and affect Latina physicians’ self-presentation over their Latino counterparts.
Findings
Gendered Cultural Taxation
Latina/o physicians explained that their Spanish/English bilingual and bicultural abilities were assets in their jobs, but often felt burdened by translation demands, with women having to shoulder this aspect of the job more often than men. Latina/o physicians noted that Spanish/English bilingualism often meant they performed tasks outside the bounds of their job description for doctors and staff across facilities. This linguistic and cultural asset resulted in extra work, with Latina physicians having to bear it more often than their Latino counterparts. For instance, Thalia, an internal medicine doctor, explained: I sent [an immigrant Spanish-speaking patient] to the GI [gastroenterologist] specialist, and they did all of these tests. She comes and sees me a month later. I ask her, “Ms. Gutiérrez, what did they tell you? What do you understand about having cirrhosis?” And she tells me, “I don’t know!” I tell her, “How come you don’t know? Didn’t you go to the specialist? What did they explain to you?” And she tells me, “Nothing. [They said] that you were going to explain everything to me.” So, I took a deep breath and I said, “me?” The patient said, “yes because you are my doctor and were going to tell me everything.”
Thalia explained that performing this type of “equity work” (Wingfield 2019) was one aspect of medicine that irked her. She was “fully capable” of translating the results for the patient, but at that moment it was the specialist’s absolute responsibility to explain to the patient in a way she understood, or to get a translator instead of sending her on her way. Thus, specialists from other facilities failed to provide translations to Spanish-speaking immigrant patients and instead relied on the referring bilingual doctors to do their work.
Yvette, who worked in pediatric medicine, explained the different workloads between her male colleagues and herself related to her linguistic abilities. She said in the span of one month, she saw over “one-hundred patients” while her white male and monolingual English colleague saw “a little above forty.” Yvette explained “they need [Latina/o physicians] in clinics,” but she also emphasized the cultural exploitation at the workplace and noticed that monolingual English-speaking doctors relied on her uncompensated bilingual labor to explain to every Spanish-speaking patient what was going on with their health. This dynamic also occurred between monolingual English-speaking staff and bilingual Latina doctors who opened their own practice, as the following vignette shows: Tessa, a white medical assistant, wearing a headset with a microphone replied, “un momento” [one moment] when the caller asked a question in Spanish. Once Perla, a Puerto Rican doctor heard Tessa say those words, she grabbed a headset and answered the call. “Hola soy la doctora. Tengo disponible a las doce. Perfecto.” [Hello, I’m the doctor. Noon is available. Perfect!] “I’ll put her here” she remarked as she put the visit into the computer system. Tessa answered another call, said one moment, and again Perla put on the headset and scheduled the visit.
Perla was one of the few Latina physicians who had opened up her own practice; however, on most days, she performed her own job tasks and those of her medical assistant. Unlike the South Asian women physicians in Murti’s (2012) study who experienced social marginalization, we find Latina physicians were not socially marginalized per se, but instead were repeatedly pulled in to provide their cultural competency by various sources without commensurate recognition for this skill.
This linguistic capital operated in different ways with their coworkers and patients. Both Latina/o doctors mentioned that women patients often preferred to see women doctors. This, coupled with being one of the few Spanish-speaking doctors, meant Latina doctors often bore the brunt of a gendered cultural tax. Laura, a family medicine physician, explained how “a lot of time, they request a female doctor if they’re female and a lot of times, if they’re Spanish-speaking, will request a Spanish-speaking physician.” They noted that Latina patients felt greater cultural, emotional, and physical comfort with Latina physicians than with Latino doctors. Raquel, an internal medicine doctor, expressed her frustration at having to see additional patients but also admitted that her men counterparts often lacked adequate compassion for women with mental health issues, which are often stigmatized in Latinx cultures. Raquel said, They don’t want to be examined by male doctors, so I get all of those. Which, excuse me, they’re doctors too! Why do I have to see them when they’re not my patients for the breast exam? The pelvic? For vaginal discharge? All of those female-related things? I’m anxious, I’m depressed . . . they feel males don’t listen to their mental health issues. And that’s probably true because men will be like, “tough it out.” . . . They come to females ’cuz they think we’re more compassionate.
Latina physicians were routinely requested by both Latinx and women patients because they perceived Latina physicians as having more feminine nurturing qualities than male doctors, such as compassion and empathy, which facilitated disclosure.
Latino physicians did not contest that they saw on average fewer Latinx patients than did Latina doctors, and a few even claimed they saw the same number of patients as white doctors. However, both Latina/o doctors described having to provide more services to Latinx patients while working under the same time constraints as other doctors. For instance, Ignacio, a family medicine physician, described how he often had to provide more services and treat more severe conditions while seeing patients, because of the lack of culturally competent doctors and lack of healthcare accessibility for low-income Latinx patients. He said, People come in with a big list and they expect you to cure their thirty years of problems in a twenty-minute visit. And that can’t be done. Latinos tend to hold a lot in, and then when they come see you, “Oh doctor, mire tengo estas preguntas” [Oh doctor, look I have these questions] and then brrrr they have twenty questions. . . . Or say they just got insurance for the first time and they’ve never seen a doctor and now they have all these chronic and vast diseases that should have never gotten there.
While bilingual Latino doctors may not be burdened with the same number of patients as Latina doctors, they do provide a considerably higher number of services to immigrant Latinx patients than do monolingual physicians. In other words, Latino doctors end up doing more work per Latinx patient appointment because Latinx patients often cannot get their needs adequately addressed by non–Spanish-speaking doctors or because of barriers to healthcare. The number of ailments Latina/o doctors address during the same 20-minute appointments conceals the additional labor performed by Latina/o doctors, especially Latina doctors who report seeing more patients than men doctors.
Additionally, some Latina/o doctors, especially Latinas, expressed discontent with their colleagues or workplaces for refusing to recognize the importance of culturally competent patient care. Whereas white women in technology experienced a small “step-stool” for their interpersonal skills, Latina doctors rarely did. Instead, Latina/o doctors were emphatic that their workplaces’ weak commitment toward promoting cultural competency was apparent in their reluctance to hire Latinx doctors, more Latinx nurses, or official Spanish-speaking interpreters. Raquel shared an instance where a colleague explicitly devalued the importance of hiring more Latinx doctors because of a translator line service available in their workplace. She recounted, When I said, “I’m so happy to work in [this city], there’s a lot of Spanish-speaking patients.” He [Asian doctor] said, “Well before you came, we were doing fine without you. We have this thing? Have you ever heard of it? It’s a translator line. So, we don’t need Spanish speakers. We got this box, and they could speak their language.”
Raquel Íñiguez’s colleague minimized her important contributions to the workplace and also failed to acknowledge the additional labor Latina/o doctors perform due to Latinx patient needs and requests. Latina/o doctors explained their cultural competence allowed them to foster trust, practice mannerisms that denote respect, understand cultural beliefs and taboos related to health, know common homemade remedios [remedies], and allowed them to better advise Latinxs on health-related matters. Karen, a family medicine physician, described how her cultural competence allowed her to better support diet changes for Latinx patients struggling with obesity, diabetes, hypertension, and heart disease. Karen said, I think most of my patients will take me more seriously than if it comes from a physician they cannot relate to. When I am explaining to them about their diet, I tell them “yes, I know you are used to eating arroz [rice] and frijoles [beans] and carne [meat] and tortillas.” This is what your plate looks like, and this is what it should look like. And then I let them fill in what it should look like.
Karen explained that it was important for patients to have doctors who looked like them and understood their home life. Gender inequality manifested itself in different ways, and bilingual Latinas working in the “token” context or as the “lonely only” often find themselves doing additional work—such as translation—that other doctors performing the same job are not asked to do. The fact that they were bilingual and bicultural Latinas pushed more of the workload in their direction.
Microaggressions from Women Nurses and Staff
Latino physicians had a distinct gender advantage over Latina physicians when it came to receiving symbolic displays of deference and respect from women nurses and staff, both Latinx and non-Latinx. Goffman (1956) explains that the appreciation carried by an act of deference implies that the actor possesses a sentiment of regard for the recipient. Relationships between women nurses and staff toward Latina/o physicians in the workplace fell into two categories: deference or sabotage. Fausto, who specialized in pediatrics, noted that he and two other men in his medical program would rarely have to do tasks such as draw blood from patients because women nurses were quick to offer to do it for them. He said, We [the men in my program] joked we would never have to draw blood or anything. We did draw blood. But looking back on the number of times I had to versus my female colleagues had to was a little different. [Latinas] had [to] way more because the nurses would offer all the time. It clearly came down to gender. I told them I think it was how nice I was? I would talk to [the nurses and say] I couldn’t draw blood . . . not in a manipulative way but I felt like I could. They [women physicians] just felt like they couldn’t do that.
Here, Fausto notes that as a Latino physician, he was rarely asked to draw blood from patients because nurses were ready to “jump in” and do it for him. In some instances, he would use guileful tactics to get nurses to perform the procedure for him because he knew he possessed a gender advantage. Yet it was the discriminatory practices of women nurses and staff that upheld and perpetuated this gender advantage for men. Similarly, Mariano, a pediatric surgeon, noted that Latina nurses and staff often performed small interpersonal acts of deference toward him. He said, I was lucky . . . I wasn’t expected to do anything. I could just do whatever I want because I was a male and [spoke] Spanish. . . . It was really amazing! If I had a charge nurse that was Mexican, I [would] get special treatment. It’s really interesting. I mean, they’d really look out for me and if there was a potluck or something, they always made me a plate and the other guy standing around will say, “Hey, where did you get the plate from?”
Mariano marveled at the fact that, because of his gender and bilingual abilities, in conjunction with being a surgeon, Latina nurses and staff would go out of their way to cater to him over Latina doctors and other white, non-Latinx physicians.
Miguel, an orthopedic surgeon, was running his own private facility. Latina staff in his private practice routinely performed deferential rituals in the workplace toward him. The following fieldnotes illustrate this dynamic: Miguel gave [the first author] a tour of his practice. He indicated that some of his employees had been working for him for 30 years, and that he had a good working relationship with them. “Am I a good boss?” Miguel yelled out as one of the Latina staff members walked out of his office. “The best boss ever!” the woman yelled back. Miguel showed me the file she had left for him. It was a list of his cases for the following day with a Post-It note that read, “Good afternoon Dr. Nuñez” with a happy face. [Fieldnotes, March 6, 2015]
Unlike men who reported positive interactions with women nurses and staff, both Latina/o physicians used the word “cattiness” to describe interactions between women doctors and nurses, reflecting a gender order in which, despite men and women having commensurate levels of education, nurses would perform small acts of sabotage toward Latina doctors. Men physicians noticed these microaggressions but blamed Latina physicians for nurses’ actions, failing to recognize their own gender privilege. Men were not attuned to how they were normalizing sexist and racist treatment of Latina physicians. Esteban, an internal medicine physician, remarked, “One of the female docs was complaining. They take things really personal. I don’t know why or how, but there sometimes can be more of a clash amongst females.” Latino doctors relished the small acts of deference they received from staff and nurses and were more likely to indicate that when nurses and Latina doctors “bumped heads” it was based on “personality” issues instead of a discriminatory gender order at work. In fact, several Latino physicians thought nurses respected them more because they were “nice” and treated nurses as important team members, even when nurses repeatedly performed tasks for men physicians that they could easily have done themselves. While Latino doctors faced marginalization because of race, they actively perpetuated and benefited from the racialized sexism and microaggressions that Latina physicians experienced (Solórzano and Yosso 2000). Janet, a family medicine physician, agreed: “I think when it comes to many nurses (males or females), they kind of don’t like taking orders from you. Who are you to give me an order?” Latina physicians tried different strategies, such as bringing nurses sweets or helping them around the office in order to gain favor, but it rarely worked. Alicia, an internal medicine doctor said, I get along with the nurses, but I know if a man walks into the hospital and says, “Where’s the labs of this patient?” The nurses go, “What do you need?” I could have been asking that nurse the same question and it would have taken her an hour, or they’re like, “Oh God, hold on Dr. Parra because this guy always screams.” And I go, “It’s not that he yells, it’s because he’s a man and you have more respect for him. You don’t realize your underlying bias because nobody is calling you out on it.”
Unlike men physicians, Latina physicians emphasized that nurses, both Latina and non-Latina, would consciously or subconsciously engage in acts of sabotage to undermine their efforts at work. These acts of sabotage took different forms, such as taking “forever” to complete a simple task for a patient while doing it quicker for a man physician. More than one Latina physician in the study described it as a “female screwing another female.” Perla said, “nurses are far more likely to question your judgment, especially if you’re a new doctor. But they do it in such a rude way a lot of the time . . . the dynamic there could be a little bit tough.” Because of this dynamic, Perla saved up to open her own private practice to avoid working with Latina medical assistants who dismissed her instructions to give injections to patients when she worked in facilities in downtown Los Angeles and South-Central Los Angeles.
Elivet, a Mexican-origin family medicine doctor, noticed these differences too, especially when a chaperone
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was in the room. She explained, “the males have chaperones for every female exam all the time. We [women] don’t because we are busier and, even if we do, the assistant will come into our room and she’ll just stand in the corner and be there as an observer. But if she’s assisting the male provider, she’s handing him the equipment.” Not only did Latina physicians narrate seeing more patients overall, but they also performed tasks that assistants would automatically do for men. Vicki echoed Elivet’s sentiments that nurses and staff were deferential to men overall. She said, I was on-call in the hospital . . . [and] I asked the RN, “Do you know where [Max] is?” and she says, “Well that’s something you can figure out.” So, she gave me attitude . . . what struck me is I’ve seen this RN interact with white male doctors, and she would never speak to them like that. At that moment I felt like, I don’t know if she knows I’m a doctor . . . because I’m female, because I’m Latina, like it’s not important. . . . I’ve personally seen this RN. You know? The 60-year-old white female. A male doctor comes in, “Oh, doctor, what do you need? Here’s your stuff.”
To command the displays of deference that male coethnics were receiving, some of Latina physicians mentioned they needed to downplay their Latina femininity (García-López and Segura 2008) and “act like men” or “talk like men” to be respected as doctors. One Latina physician even said she was told to speak with a deeper voice at a professional training. Yet being assertive on the job was not always interpreted favorably. Janet, in family medicine, reported: It has to do with me being a woman more than anything else. [Nurses] just make your job a little more difficult to do. . . . This is actually within the Latino spectrum. . . . The women I feel like if you don’t say something the right way or if they perceive anything they think was wrong, they make a big fuss about it.
Thalia also explained that being assertive to get the results she wanted from staff was a source of conflict in her job. She said, I find it’s a hindrance if I am assertive. They see that as negative. My nurse will tell me when she’s off nobody wants to work with me (laughs) and that’s true. Es porque soy exigente [it’s because I’m demanding] and it’s not any different than being a male, right? . . . I want you to do your job. . . . I have high expectations because I feel you represent me.
Janet and Thalia both demonstrate how having high expectations would have been met differently by women co-ethnics if they were men. Women modified their behavior so their coworkers would follow through on their tasks, but on most occasions they did it themselves.
Authority and Competence Questioned
Latina/o doctors were cognizant of the stereotypical social identities and phenotypes that were associated with being a doctor. Thomas, an internal medicine physician, described the occupation as a “white man’s game and workmanship.” Latina/o doctors were explicitly made aware of the fact that they did not fit the mold of what a doctor is presumed to look like. Vicki, a 35-year-old family medicine physician, shared an instance where a patient told her she did not fit the mold because she was not “white, old, and with gray hair.” Not fitting the mold had negative repercussions for both Latina/o doctors, however, to varying degrees. Age and the intersection of other social identities affected the type of challenges Latina/o doctors experienced and how they navigated self-presentation in the workplace.
Both Latina/o doctors described instances in which they were not readily accepted as doctors and in which patients assumed they were not the attending doctor because they looked “too young.” However, Latina doctors stated that it was more common that patients mistook them for holding a lower-status health occupation, much like the Latina lawyers in García-López and Segura’s (2008) study. Luisa, a 36-year-old Mexican American doctor, explained that because of her age and gender, she was commonly mistaken for staff of a lower occupational status. Luisa said, “In general, people don’t think I’m the doctor. They think I’m a nurse, or I’m an assistant or housekeeping, and that happens to me a lot. . . . Patients, nurses, housekeeping staff and the O.R. I had one of the housekeeping staff [ask] me if I was a doctor because I was too young and female.” Numerous Latina doctors reported their family, peers, and patients thought that they were nurses, and were more likely to mention this was particularly salient when they were young (see Portillo 2010).
Beyond dealing with the constant skepticism about being doctors, Latino/a doctors also reported that because of their age, their judgment or expertise was often challenged by nurses, patients, medical students, and even their colleagues. Mario, a 37-year-old internal medicine physician, described how his age and being Mexican contributed to patients questioning his expertise. He said, older patients feel “if you are a minority or you are too young, you may not have received appropriate education.” Mario explained that on top of being young, patients were skeptical about his credentials because they assumed Latino doctors were not adequately trained. Rocío, a 37-year-old rheumatologist with 10 years of practice, shared a few incidents that made her believe that people did not respect her and value her opinion because she was a “young woman.” In one of these instances, Rocío was assigned to treat a patient who happened to be the son of a prominent figure. While working on this case, Rocío described feeling that her colleagues undermined her by asking an older, white, man doctor about his perspective instead of directly speaking to her. She said, Instead of coming to me, they went straight to him! It’s like . . . he’s not even officially on the case. It’s me! But he’s the name everyone knows; he’s more established even though I’ve been here five years. . . . I was the one doing the research and came up with the diagnosis and figured out the treatment plan, but still, they were going to him.
Although both Latina and Latino doctors had their expertise scrutinized because of their age, only women reported experiencing sexual harassment from patients. Some of the Latina doctors experienced unwanted comments about their appearance from patients and remarked this was due to their age. Laura (32 years old) expressed how being a young family medicine doctor sometimes led to unwanted attention from patients. She said, It can be difficult at times. . . . There have been instances where I’ve been hit on by patients. A lot of times I’ll go in and, they’re like, “How old are you?” That’s the first question I get asked. “You must be eighteen right out of college.” That makes me feel like they don’t trust me or they’re not taking me seriously. So, you have to put your best foot forward and kind of not let that affect you, but it does a little.
Laura surmised her young age was an opening for unwanted attention, and even though she tried to brush it off, it still affected her confidence. Latina doctors also experienced racialized sexual harassment (López 2003) at work events. Elivet (36 years old), a family medicine physician of Mexican origins who was of a darker phenotype, narrated an unpleasant interaction with an Asian physician. She explained, I was at a dinner dance [work event] with my husband and I was very made up. . . . I curled my hair, and I was wearing a nice dress. [An Asian male doctor] made a comment to me about being Donald Sterling’s
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girlfriend. My husband is Mexican and very fair-skinned. . . . [My husband] kind of took it like saying, “nice job guy” [elbowing] . . . like he was kind of congratulating my husband for getting this hot chick who could be some dumb bimbo, right? I was very offended because I was like, “I’m the doctor here!”
The comparison made by the Asian doctor assumed that Elivet’s husband was a white man who held more power and prestige than she did, all the while relegating her to arm candy because of her age, gender, and phenotype. Elivet emphasized that this comparison was offensive because the Asian doctor’s comments about her appearance made it apparent that young Latina physicians were further disrespected when they enhanced their femininity.
To mitigate ageism, women were more likely than men doctors to say they modified their self-presentation. Luisa, a 36-year-old ophthalmologist, explained how she modified her personality to address the disrespect she received when her coworkers would move her scheduled time in the operating room without notifying her. She said, They [Asian and white men doctors] think, I should be nicer or, they think they can get away with things the males would never tolerate. . . . I find myself making up for that sometimes where I have to be a little bit more serious or more stern. I really voice my opinion so people don’t think they can push me aside.
Latina doctors tried to change their self-presentation to adopt more masculine traits and avoid traits typically associated with femininity—for example, being kind, nurturing, or accommodating.
Latinos, on the other hand, were more likely to say they tried to overcome the ageism colleagues and patients subjected them to by “proving themselves” or subtly modifying their physical appearance. Unlike Latinas, men were more likely to say that despite being young, they could “prove” their competence and gain respect from patients and colleagues. Roger, a Mexican American trauma surgeon, believed the ageism he experienced from his colleagues was temporary and that he merely needed to prove his capabilities to be treated as an equal colleague. More important, the experience was fleeting. He said, Early on, some of the older cardiologists or pulmonologists were a little intimidated by this young Latino guy . . . like a little challenge and they wanted to see what I knew. . . . I experienced that early on, but I’m not so sure that was a racial thing. I think that was like a new buck in town thinking he’s it. . . . We need to put him in this place. So, I thought there was—not hazing, but there was a little bit of a period . . . the first six months I started working that I gotta prove myself.
Similarly, Esteban, a 38-year-old internal medicine doctor with nine years of practice, indicated that he could eventually persuade patients of his competence and challenge their age-based biases by simply growing out a beard. He said, I never had a beard until I was probably in residency. . . . I grew it out. Because I kept getting that question. I did have some patients who were really hesitant for me to do procedures. They’re like, “Oh, why don’t you get your attending or someone else?” I’m like, “No I can do this.” I would kind of have to talk them into it. And then, in the end, they’re comfortable with my knowledge base.
Growing out a beard made men look older and simultaneously more “masculine.” While women may have been able to use make-up or hair to appear older, some refrained from doing this to avoid accentuating their femininity, which would also subject them to disrespect (Ong 2005). However, Cecilia, a 62-year-old Mexican-origin cardiologist, said that at her age she stopped worrying about this and did “the whole shebang.” Cecilia made it a point to wear pink suits, high heels, paint her nails, and dye her hair. Thus, both Latina/o doctors said that as they got older, they were able to avoid age-related stigma. Although being older lessened the amount of skepticism surrounding Latina doctors’ expertise, gendered and racialized stereotypes of Latinas’ occupations meant they were still frequently mistaken as holding less prestigious healthcare occupations or were taken less seriously.
Conclusion
Medical institutions have been characterized as highly gendered and racialized organizations, in which Latinas/os are severely underrepresented. We center the unique experiences of Latina/o physicians who have “made it” (Solórzano and Yosso 2000) by having completed the rigors of medical school and made significant strides into a nontraditional and masculinized career. This research makes theoretical contributions to scholarship on gender stratification in higher education in medical schools in two primary ways. First, we use an intra-Latina/o dynamics lens to analyze how gender is stratifying men and women in medicine. Second, we show how science and medicine are not culturally neutral forums, even though there is a presumption that they are (Ong 2005). Gendered demonstrations of deference and demeanor elucidate how Latina/o physicians experience entry into medicine in their everyday interpersonal interactions. This is important to consider, because changing demographic trends in the United States suggest that all physicians will be more likely to work with immigrant Latinx families who embody a host of cultural differences.
Latina and Latino doctors experience gendered racism, which can be seen in three ways: gendered cultural taxation, gendered deference, and the gendered line of questioning of competency. When examining racial discrimination among Black doctors, Wingfield and Chávez (2020) note that Black physicians indicate that racial discrimination is more likely to be experienced by those who hold positions in the lower ranks of the medical world. However, Latina physicians recount performing culturally competent tasks at all levels of the medical hierarchy, in their own specialty, for nurses and staff, and for medical personnel in entirely different facilities. We find that everyone—from physicians to nurses and staff to patients—is complicit in maintaining this inequality across the medical education pipeline and into their jobs. Gendered racism rears its head into the medical world no matter how accomplished Latinas/os are, with women having to shoulder the lion’s share of work. For instance, college-educated Latina doctors, as professionals in the white-collar world, never imagined that physicians from other facilities would be piling their work on them.
While both men and women physicians faced cultural taxation (Padilla 1994) from patients and doctors, Latina doctors bore the brunt of it because they were often preferred by immigrant Spanish-speaking women patients, who were more likely than men to seek regular health care. In this case, bilingual and bicultural abilities primed Latinas for more uncompensated and unacknowledged work indicative of a gendered cultural tax they had to pay. The gendered cultural tax is a covert workload escalator, and, like high blood pressure or hypertension, it can be a silent professional killer for bilingual and bicultural Latina physicians if they do not receive support or are recognized as professionals with unique strengths. We find that performing equity work yields different types of labor tasks depending on the group in question. Nurses and staff, both Latinx and non-Latinx, also performed subtle acts of sabotage or microaggressions toward Latina doctors, showing a type of gendered hostility toward them while exalting Latino doctors. Last, younger Latina doctors often had their expertise challenged by patients and experienced instances of racialized sexual harassment from patients and other doctors—something unheard of from men. Thus, medicine can affect Latina physicians’ own quality of life in the long run.
Moreover, self-presentation matters in the medical world. We find that demonstrations of gendered deference matter for retention rates among Latina doctors. Taking cultural understandings of gendered deference and demeanor provides a next-generation framework to create higher education institutions that reflect the populations that institutions seek to recruit from and intend to serve. Medical organizations not only should deem bilingualism an asset, but should also offer higher compensation for possessing this skill by working a stipend into the physician’s salary to remunerate them appropriately for doing this labor. Because the data reveal that Latina physicians are disproportionately performing this labor, the compensation should account for the average number of patients they see for whom doctors must use their bilingual skills to provide care. Failure to implement formal policies that address gendered deference in medicine could potentially serve as a deterrent and push Latinas to exit STEM at multiple points in their trajectories. Doctors begin to get socialized into the profession as medical students and are exposed to a host of cultural, gendered, and racialized biases early on. Placing formal rules that describe lack of gendered deference as noncollegial behavior in the workplace would protect not only Latina physicians in medicine but all workers and patients.
One of the strengths of our research is that we highlight intra-group dynamics for Latinas/os who have gone through medical school and are now a part of the medical world that will train future doctors. Although respondents included in the sample reflect the heterogeneity of the Latinx population in the state of California and identified as Mexican, Central American, South American, and Puerto Rican, none were Dominican or Cuban. Cuban physicians working in places such as Miami, Florida, may narrate different experiences. Moreover, global analysis highlight that more than 60 percent of physicians in Cuba are women and are concentrated in specialties such as neonatology or pediatrics (Burke 2013). Therefore, future research should compare and contrast physicians trained in the United States and those who are trained in a country that practices medical diplomacy. Last, this work also highlights the need for translators who speak multiple languages and are compensated for their labor in order to create more equitable and inclusive spaces for all physicians and patients.
Footnotes
Acknowledgements
We wish to thank the physicians who participated in the study. We are also grateful to the editor and the anonymous reviewers for their thoughtful comments.
The author(s) disclosed receipt of the following financial support for research, authorship, and/or publication of this article: the Hellman Foundation and UC/ACCORD support the research presented here.
Notes
Glenda M. Flores is currently Associate Professor and Director of Undergraduate Studies in the Department of Chicano/Latino Studies at the University of California, Irvine. In her work, she explores the life trajectories and workplace experiences of the children of Latino immigrants in white-collar occupations.
Maricela Bañuelos is currently a doctoral student in the Department of Sociology at the University of California, Irvine. In her work, she explores the pathways of first generation Latinx students who matriculate into doctoral programs.