The Integration of Gender Medicine in Medical Education at Austrian Universities – the Status Quo

The work at hand examines the current status of the implementation of Gender Medicine in medical education at all Austrian universities. To date no systematic studies have been conducted on this subject. This study covers public as well as private universities. The methodology was to first conduct a document analysis, followed by a questionnaire survey. Analysis of the documents showed that Gender Medicine is often combined with affirmative action for women, equal treatment and/or gender studies. These subjects are frequently combined in order to meet legal requirements, which often results in unclear and vague statements of goals. The results show that, at least formally, Gender Medicine has been integrated at all the Austrian universities by being anchored in their curricula. Actual implementation in everyday university studies has been achieved very differently at the various universities and is more or less sustainable. The development of uniform standards and criteria would be a next important step for the Austrian universities.


Introduction
Gender Medicine is a relatively new field of medicine that originated in the women's health movement and that focuses on the study of possible differences between women and men with regard to health, illness, course of an illness and access to the healthcare system (DeCola, 2012;Hochleitner, Nachtschatt, & Siller, 2013;Miller et al., 2013). One of its basic premises is to use new findings on the "advantages" of one gender to develop better therapies,

Research Aims
The aim of this study was to draw up a systematic overview on the current status of the implementation of Gender Medicine in medical education as well as its structural, thematic anchoring at Austrian universities. Against the background of research-oriented teaching at Austrian universities, Gender Medicine research is also incorporated in the analysis.
Working from the legal prerequisites for public and private universities and a standardized survey of all medical universities in Austria, the study covers all the Gender Medicine offerings in teaching and research and their structural anchoring at the universities and discusses the differences in development at the various universities. Surveying public and private universities permits a chronological comparison of the current status of implementation and also an analysis of how differences in the legal basis or the size of the (private) universities affect the type of implementation. Nachtschatt U, Steinboeck S, Hochleitner M MedEdPublish https://doi.org/10.15694/mep.2018.0000013.1 Page | 3

Methods
The study combines the methodological approach of a document analysis and a standardized questionnaire survey that supplements the content. The survey was conducted in two steps. In a first step the authors examined the legal basis for public and private universities and the legally binding documents to be drawn up by universities. The survey of the legally binding documents and the public documents that the particular universities must draw up was performed by Internet search. This approach was chosen because these documents must be made public and thus were available for the purposes of the study. The legally binding university documents employed in the analysis are shown in Table 1. One restriction of this study was the fact that not all documents drawn up by a public university were made available, despite the fact that the universities are bound by law to do so (See Table 4: Gender Medicine/equal opportunity in legal documents (public universities)).

Organisation Plan Charter
Women's Affirmative Action Plan   In a second step, data were collected directly at the universities using a standardized questionnaire. After an initial telephone contact was made, the questionnaire was emailed to the contact person, who was identified from the university's home page and by asking for information within the university.
This two-step procedure ensures that the resources and goals of the individual universities were able to be related to the actual implementation of Gender Medicine. This clearly shows differences caused by variations in personnel and structural prerequisites and framework conditions.
The questionnaire (Appendix 1) covered the following areas: 1. Data on the university: In order to contextualize the findings, information on the universities was collected. This information ensured that the framework conditions of the various universities were taken into consideration when interpreting the results. This part of the survey contains the following characteristic factors: • name of the university • total number of staff

Data on teaching:
Subsequently investigated were how Gender Medicine is integrated into the medical curriculum. Surveyed were the compulsory courses and electives offered on Gender Medicine. Data were also collected on the course type, number of hours offered, post-graduate offerings on Gender Medicine and when Gender Medicine was first taught at the university.

Data on research and additional offerings:
The questions on Gender Medicine research activities concerned the number of research projects, publications, scientific lectures, diploma theses, doctoral theses and poster presentations. An additional section of the questionnaire served to collect data on the possible additional offerings that support teaching and/or research of Gender Medicine. These include, for example, guidelines, advisory sessions, methodological tools and awareness campaigns.

Data on structural anchoring:
The questions about how Gender Medicine is structurally anchored aimed to determine which departments or organizational units were concerned with this subject and how they were staffed.

Data on local and regional networking:
Integration of Gender Medicine in the region was covered by questions on regional networking and public relations work. These questions provide information on regional partner institutions, forms of cooperation and anchoring in the region.

Data on planned activities:
The survey concludes with an open question on planned, future activities concerning teaching Gender Medicine. The data were collected at the universities from February to June of 2017. All seven Austrian universities that offer medical education were invited to participate; six took up the invitation. The Medical University of Graz was able to participate only in the document analysis of national and university legal foundations; no data were received on course offerings or Gender Medicine research. The Sigmund Freud Private University Vienna participated in the survey, but currently has no offerings for Gender Medicine in teaching or research.

Results
The universities studied differ greatly from one another with regard to their size. The number of staff and of students is considerably larger at the public universities than at the private universities. Of the public universities in Austria the University of Linz holds a special position with its Faculty of Medicine that was opened in 2013.   Table 4 shows the university-internal legal documents that anchor Gender Medicine at the public universities. Since the legal prerequisites are diffuse with regard to the contents to be presented, Table 4 shows not only those passages that specifically and exclusively mention Gender Medicine, but also those that treat Gender Medicine jointly with  The phenomenon of synonymous use of teaching and research for Gender Medicine and equal treatment is also found in the corresponding legally binding documents drawn up by the private universities. Here, too, we see that Gender Medicine and equal treatment are often treated jointly (see Table 5).

Internal Legal Documents
Charter y y y

Information Material
Information Brochures for Students y y -Strategy Papers /Concepts (Line Professional Development) y -- All in all, it is seen that at all seven universities studied the subject of Gender Medicine [2] has been integrated into the documents that universities must draw up. Thus, it is clear that all the universities must have at least discussed Gender Medicine, even if the necessary brevity of the texts does not give an indication of how sustainably anchored Gender Medicine is or how much it will continue to be discussed. This level of integration of Gender Medicine deals solely with the formal legal basis for real-life practice. All universities meet the legal prerequisites. Implementing Gender Medicine, evolving courses, defining contents or providing offerings additional to those in the declarations of intent in the legal documentation are linked to a structural anchoring of Gender Medicine and clear responsibilities and duties. The answers to the questions about different possibilities for structural anchoring are found in Table 6. The questions asked whether a chair is endowed for the subject of Gender Medicine as well as organizational units and how well they are equipped with staff. The table shows that the two medical universities in Innsbruck and Vienna that have such a chair also have more resources with regard to organizational units and scientific staff. An organizational unit for equal treatment and gender studies, as set forth in Section 19, para. 2, Item 7, Austrian University Act 2002 (Universitätsgesetz 2002), is also given at the University of Linz. It is, however, responsible for the entire university and thus not only for Gender Medicine. It is conspicuous, however, that the two private universities in Krems and Salzburg, that are under no legal obligation to establish an organizational unit for Gender Medicine, chose to appoint a contact person for Gender Medicine.

Public Universities Private Universities
Innsbruck Linz Vienna Krems Salzburg Vienna One step further into actual everyday university life the question is raised whether there are course offerings in Gender Medicine. Table 7 shows the offerings of the various universities broken down for compulsory and elective subjects and the number of additional post-graduate courses offered. Also given is the number of hours per weeks per semester the course is held. The two medical universities in Innsbruck and Vienna started roughly ten years sooner with implementation of Gender Medicine; as public universities they are also larger. Both of these medical universities show differentiated offerings with a different focus. At the same time the universities in the process of evolving (Linz, Krems) show that Gender Medicine offerings were planned and introduced as a compulsory subject right from the start.  Decisive for a discipline to be anchored in everyday university life is not only the teaching of that subject, but also how strongly research is conducted in that field.  In addition to Sex and Gender Medicine research projects, advising on diploma theses and dissertations as well as publications, the various universities also provide additional offerings to support the evolution of knowledge, competence and skills in the field of Gender Medicine and thus to ensure the transfer of knowledge to the scientist's own practice. These offerings are best developed at the universities that introduced Gender Medicine very early: Innsbruck and Vienna. They include guidelines for defining Gender and Diversity, on how to use gender-sensitive language or convey methodological competence, online building blocks, tools for sensitization for Gender and Diversity or for information events for the purpose of integrating sex-and gender-specific aspects into grant applications.

Public Universities
Networking with external partner institutions is weighted differently at the various universities. Gender Medicine.
The study results show whether and to what extent Gender Medicine in teaching and research is anchored at the Austrian medical universities and faculties and what structural resources are available. Questions about qualitative parameters, such as content, quality criteria and standards, cannot be answered from the available quantitative data. For this purpose, an additional study would be needed. Nevertheless, the data compiled here permit several tendencies to be identified.
[2] The terminology used is not uniform: the term Gender Medicine is not always explicitly used. In some cases, it is said that equal treatment and Gender Studies will be given consideration in teaching and research. However, Gender Studies at medical universities primarily means Gender Medicine.

Discussion
In addition to the teaching offerings, the legal prerequisites, the structural integration of the university units holding the offered courses, the personnel resources as well as any possible additional offerings (for example, advisory offerings, resources for teachers, training sessions) were surveyed. The anchoring of Gender Medicine in medical education varies from region to region, even if the (legal) framework conditions and prerequisites are similar. Legal differences are found only between private and public universities. For example, the Austrian University Act (Universitätsgesetz 2002) that governs all public universities in Austria stipulates not only general commitment to equal treatment and affirmative action for women, but also that universities must draw up an equal treatment plan and set up an organizational unit to coordinate the tasks of equal treatment, affirmative action for women and gender research. The Austrian Private University Act (Privatuniversitätsgesetz) states, in addition to a general commitment to compulsory equal treatment, that it is to be decided in an internal charter. Legal framework conditions are necessary prerequisites. However, legal requirements in their general and vague nature are not sufficient and permit a lot of creative leeway. A differentiated description and definition of the three levels Women in Science, Gender in Science and Science of Gender (Keller Fox, 1995) would make it easier to put the legal prerequisites into practical implementation. The leeway seen in the study ranges from a vague commitment to equal treatment in research and teaching in one of the charters, which is followed by no definite implementation in curriculum or organizational structure, to setting up chairs and comprehensively implementing Gender Medicine in teaching. Despite the fact that Austrian law makes fewer stipulations for private universities, Gender Medicine is taught at the private universities in Salzburg and Krems, whereas the teaching of Gender Medicine is not apparent at the public University of Graz. University size, how much time has elapsed since introduction and more specific legal prerequisites for public universities are not the only factors that determine whether and how Gender Medicine was or is established. This different way of dealing with similar legal frameworks leads one to conclude that the specific realization at the individual universities is dependent not only on the above factors, but also on additional aspects, such as for example specific persons at the particular universities, who bring the right interest and dedication and have the necessary power to act and implement. The important role of specific persons is also emphasized in studies conducted in the United States and Europe, but also the need for broad university support and good structural foundations (Hiltner, 2016;Miller et al., 2016).
A clear difference between the public and private universities is seen in the provision of resources. The legal prerequisites give the public universities better resources, they must have an organizational unit and must draw up a women's affirmative action plan/equal treatment plan. These prerequisites make it easier for university staff to develop definite measures and projects for teaching and research. The goal of a chair for Gender Medicine, as stated in the women's affirmative action plans drawn up by the medical universities in Innsbruck and Vienna, was realized by both universities. These chairs make it possible to provide a broader range of course offerings and promote research on the subject. The extent to which the factors already named -legal prerequisites, personnel and financial resources, the time factor as well as the role and the dedication of individual persons -interact and are mutually dependent is seen from the example of the Medical University of Graz: like all public universities, the Medical University of Graz has an organizational unit, an affirmative action plan for women and strategy plans that at least partly include the teaching of Gender Medicine. And still, it was not always clear who was responsible for what, nor was it possible to obtain the specific data by means of the questionnaire. This problem points to a structural deficit, but does not mean that there cannot be Sex and Gender Medicine activities in teaching and research. However, this cannot be determined in a form that would be comparable with the other universities.
The study also shows that the factor time plays an important role. From the public University of Linz and the private university in Krems, where the medical education program is still in its infancy, we see that at the time of the study, i.e. in the early years of curriculum development, the integration of Sex and Gender Medicine teaching was the first priority. Only later was more attention given to research and/or the development of additional offerings. The universities of Innsbruck and Vienna have both completed these development phases.

Conclusion
The small number of (private) medical universities does not permit any general conclusions to be drawn from the study results. The study does, however, comprehensively show the current status quo of research and teaching with regard to Gender Medicine and its structural anchoring in Austria. The development has picked up momentum thanks to the fact that there are two additional medical universities in the process of establishing themselves and because the integration of a Sex and Gender Medicine perspective of health and illness seems to be becoming more matter of fact. The fact that a chair has been set up at two out of three of Austria's public medical universities is a success. At the same time, it is seen that development has occurred differently at the various universities and that different concentrations have been installed. Precisely the universities currently in the process of establishing themselves could profit from an exchange of ideas on experience and cooperation for specific projects, and thus spare themselves having to reinvent the wheel. For example, knowledge transfer, that goes beyond purely Sex and Gender Medicine research (including methodological competence, gender-and equal treatment-sensitive communication and language, grant applications), is of great importance and needs to be stabilized. Continuation of the synopsis of qualitative issues commenced in this study would also be desirable.
The study also shows that Gender Medicine has not been comprehensively established at all the universities offering medical education. This shows that compulsory laws alone are not sufficient. In addition to the pertinent Ministry's obligation to formulate concrete equal treatment and Gender Medicine goals and ongoing checks for their realization, offering additional funding as an incentive would also be appreciated (Kamphans, 2014). A clear distinction between equal treatment measures at the personnel level and Sex and Gender Medicine research and teaching, i.e. giving consideration to the category gender at the contextual research level, would seem to be a productive step.
The study results show that the national development of Gender Medicine at the Austrian universities has taken a form comparable to that in North America and the other European countries (Harreiter, Thomas, & Kautzky-Willer, 2016;Miller et al., 2016;Rojek et al., 2016)

Survey of Gender Medicine at Austrian Universities
Dear Colleague, We are very pleased to have you help us survey the teaching of Gender Medicine at Austrian universities.
Gender Medicine is, on the one hand, a cross-cutting subject involving all medical disciplines that concerns differences between women and men with regard to various illnesses and, on the other hand, it has also established itself as a separate discipline that aims to impart fundamentals, definitions, methodological know-how and an awareness for often still lacking medical research data.
It is a known fact that many course instructors mention differences between the sexes in their courses and therefore we put the focus of this questionnaire on Gender Medicine as an explicit discipline in its own right, i.e. where, in addition to the above contents, the differences between women and men are the primary focus of the course. How well is Gender Medicine accepted as a subject, in which medical study programs, to what extent is it taught? What additional offerings and Gender Medicine research results can the Austrian universities show? Since the data for 2016 are not yet complete, we ask you to kindly use the year 2015 as your reference year for teaching and research.
In the event that the information requested in the questionnaire is to be obtained from several persons, kindly request the information, enter it in the questionnaire and return it to us. Should you have any questions, we are at your disposal at all times: ……………………………….

Post-graduate Teaching Gender Medizin
This section refers to course offerings aimed at participants with a first university degree.

Local and Regional Networking and Public Relations Work of the University
With what local and regional institutions does the university work with regard to Gender Medicine?

Future Plans
Are there plans for future teaching and/or training offerings that involve Gender Medicine?

-Yes -No
If yes, which?

Thank you!
Appendix 2: Documents of the public and private universities that were included in the document analysis