When doctors deny drugs: Sexism and contraception access in the medical field.
Author: J. B. Delston
Delston JB. When doctors deny drugs: Sexism and contraception access in the medical field. Bioethics. 2017;31(9):703-710. doi:10.1111/bioe.12373.
Politicians, employers, courts, and health insurance companies are often discussed as problematically preventing access to birth control. However, doctors have more direct control over women's health and quietly have been much more effective at preventing patients' access to contraception. Obstetrician/Gynecologists routinely deny their patients access to contraception ostensibly in the name of health by withholding birth control until patients undergo yearly pap smears. I argue that those in the medical field are motivated by similarly sexist concerns as those in other major institutions in the United States, but that they are often overlooked in discussions of biomedical ethics. After providing background, I argue that using birth control as a bargaining chip to control patients is morally impermissible, is paternalistic, and is contrary to consent. I next argue that sexism explains, though does not justify, this practice. I discuss the medical harms of routine pap smears and withholding birth control. These claims make medical malpractice likely. Withholding birth control to coerce individuals seeking medical care is medical malpractice, paternalistic, violates autonomy, and is contrary to consent.
applied ethics; biomedical ethics; contraception; feminism; obstetrics; gynecology; informed consent
Recently, valuable discussions have arisen surrounding the availability of birth control in the United States and the various groups of people trying to restrict access to it. Politicians,[ 1] employers,[ 2] courts,[ 3] and health insurance companies[ 4] have all made significant efforts to limit or eliminate access to contraception. However, another group with arguably more direct control over reproductive health quietly has been much more effective at preventing patients’ access to contraception: doctors.[ 5] I argue that those in the medical field are motivated by similarly sexist concerns as those in other major institutions in the United States who seek to limit contraception access, but that they are often overlooked in discussions of biomedical ethics.
Obstetrician/Gynecologists routinely deny their patients access to contraception ostensibly in the name of health by withholding birth control until patients undergo yearly pelvic exams and Pap tests. In this article, I argue that this practice is unjustified. I first establish the phenomenon that serves as the main topic of the article: physicians impose medically unnecessary restrictions on patient access to birth control prescriptions and refills. Next, I argue that using birth control as a bargaining chip to control patients violates autonomy, is paternalistic, and is contrary to consent. In the third section, I argue that sexism explains, though does not justify, this practice. I next consider the physical harms of the practice, which bolsters support for the medical malpractice claims I make in the next section. From a strictly medical standpoint, this charge is gaining traction in the literature; many now argue that the harm this practice does to patients makes it unacceptable.[ 6] However, the literature mistakenly focuses on the biological outcomes alone. In this article, I argue that even if yearly Pap tests were likely to lead to positive outcomes, and even if the withholding of birth control did not physically harm patients – that is, even if doctors violate patients’ choices to preserve patients’ interests – the practice still would be unjustified.
DOCTORS ROUTINELY DENY PATIENTS ACCESS TO BIRTH CONTROL
Despite the availability of more effective forms of contraception such as intrauterine devices and implants, or long acting reversible contraceptives (LARC),[ 7] a large proportion of people in the US rely on hormonal birth control. More than a third of contraception users rely on hormonal birth control methods, more than any other form of contraception.[ 8] Twice as many women rely on hormonal contraceptives than on the male condom as their method of birth control and 4 out of 5 women with sexual experience have used the pill at some point in their lives. Despite its prevalence, high demand, effectiveness, and safety, significant parties aim to limit patient access.
Obstetricians/gynecologists generally require pelvic exams and Pap tests before offering prescriptions for birth control.[ 9] This requirement is not new. Doctors have long tied birth control prescriptions to Pap tests and pelvic exams, doling out 1‐year prescriptions in the expectation that renewals occur at yearly checkups. The exact percentage of doctors that require their patients to go off their medication is hard to come by, as it relies on physician surveys.[ 10] Furthermore, since this practice currently flouts standards of care, doctors may not be forthcoming in such surveys.[ 11] Some put the percentage of doctors generally requiring these examinations for birth control at nearly 50%.[ 12] Other studies show 65–85% of doctors recommend Pap tests every year.[ 13]
For example, according to one study, 97% of doctors required Pap tests before refilling an oral contraceptive prescription.[ 14] Another study shows about three quarters of doctors requiring annual Pap tests for patients starting at age 18, regardless of sexual activity.[ 15] In another study focusing on pelvic exams, about one third of Ob/Gyns reported always requiring the exam before prescribing birth control and another 50% reported usually requiring it.[ 16] Fewer than 5% never required it. Among all clinicians in this study, which included family practitioners and nurses, the numbers were not much better. About 2 out of 3 practitioners always or usually required pelvic examinations for contraception refills while almost 5% never required it.[ 17]
In that study, the most significant indicators as to whether physicians required the test were the characteristics of the physicians and the patients they serve:
Providers in private practice were more than twice as likely as those working in family‐planning or community clinics to require pelvic examinations (OR 2.30, P<.01). Clinicians from the South (OR 1.70; 95% CI 1.10–2.62) and those reporting that half or more of their patients are insured by Medicaid (OR 1.62; 95% CI 1.11–2.37) were also more likely to always require pelvic examinations for oral contraception.[ 18]
Multiple studies found older physicians were less likely than their younger counterparts to prescribe birth control without a Pap test or pelvic exam. However, both groups required the tests at extremely high rates. Doctors in the South are more likely to impose restrictions, meaning that Southern patients are more likely to face problems, although significant restrictions apply to all patients.[ 19] In addition, since doctors who serve communities insured by Medicaid are more likely to require exams for contraception prescriptions, we know that poorer patients face greater obstacles in gaining access to birth control than wealthier ones. Since poorer patients are also the least likely to be able to handle such obstacles, we can assume that at least some poor patients who want birth control and have access to doctors through insurance are not receiving it.[ 20]
As stark as these numbers are, showing a significant proportion of doctors posing unnecessary obstacles to patient access to contraceptives, they may present a rosier picture than reality would indicate. Studies tend to acknowledge these limitations: ‘Social desirability bias could affect responses, with clinicians indicating idealized or professionally normative practices.’ [ 21] In other words, the disparity between theory and practice is likely to lead to doctors inflating their own compliance with the guidelines. Especially in the context of a survey in which doctors are self‐reporting and communicating with agencies they can presume are evaluating their behavior, doctors may be incentivized to stretch the truth on how often they follow guidelines. In addition, the surveys rely on vignettes of patient scenarios with attached questionnaires rather than requesting clinical data on what proportion of patients face these obstacles. As a result, doctors may be more likely to see themselves as following guidelines in hypothetical scenarios while contradicting guidelines in actual practice.
Surveys of patients confirm the data we have on physicians. For example, one survey found that a significant percentage of women and girls under the age of 25 reported having undergone a Pap test in the previous 12‐month period despite never having had sex.[ 22] That means that millions of patients are undergoing a test for a condition that comes about primarily from a sexually transmitted disease despite never having had sex. In addition, since that survey only asked whether individuals had received Pap tests in the previous 12‐month period, it is very likely that a much larger percentage received these unnecessary tests.
This practice inevitably leads to reduced access to birth control for many patients.[ 23] The examination poses a cost in time and planning, just as any mandated waiting period imposes costs. A doctor's appointment is a considerable time investment, especially for hourly workers, patients with dependents to care for, or patients who travel. Additionally, if patients cannot get an appointment in the allotted time frame, forget how many refills they have left, are menstruating at the time of the appointment, switch jobs, lose a job, or have other changes in insurance, this requirement may lead to a lapse in coverage. Such patients will have to go off the pill, either for days or for weeks, until such time as they can undergo an examination. There is no doubt, then, that doctors routinely deny and threaten to deny patients access to birth control. Is it permissible for doctors to withhold prescriptions for yearly Pap tests and pelvic exams either due to protection of patient interests, physician principles, or to improve health outcomes for patients? In the remainder of the article, I argue that such practices are never justified.
MORAL PROBLEMS WITH LIMITING ACCESS TO BIRTH CONTROL
In this section, I argue that limiting access to oral contraceptives violates patient autonomy, is paternalistic, and damages informed consent.
Autonomy
When patients act out of free will to pursue choices that reflect their considered opinions, they act autonomously. Treating patients as autonomous protects their right to govern themselves and allows them the authority to determine their own lives. Respecting autonomy acknowledges the full agency of actors as capable of setting their own goals and acting on them. Adult patients with rational capacity are uniquely qualified to determine what best serves their interests; to go against these decisions treats them as less than persons. Autonomy is an extremely weighty moral value and overriding it requires an equally weighty or weightier reason. In biomedical contexts, we recognize the fact that individuals’ goals and values differ, so we allow them as much choice as possible in pursuit of those goals. A longer life is not always valuable to patients who endure extreme and untreatable suffering; a better quality of life is not always valuable to patients who think any medical intervention disrupts God's plan. Adhering to patient values protects their autonomy.
Overriding or ignoring patient choice is disrespectful of their autonomy, even when it falls short of medical negligence or malpractice, because it upsets their decision‐making and values. For example, doctors should respect the decision of a patient who does not want a screening for Huntington's disease, despite having a 50% chance of having it, without threatening other sorts of care.
In this case, doctors override patient autonomy first, by requiring a test the patient may not want, and second, by withholding needed medical care the patient does want. In each case, doctors rely on personal values instead of on patient values and wishes. Respect for autonomy rules this practice out as impermissible.
If some do value autonomy, or value it only instrumentally, my argument does not require commitment to this concept.[ 24] In the next sections, I look at other philosophical reasons to reject the practice.
Paternalism
Suppose no risks attended Pap tests. Suppose they never caused pain or worry. Suppose no false positives ever arose, and thus no harms were ever done by overtreatment or unnecessary surgeries. Suppose they cost patients no money and suppose the opportunity costs of the time spent in appointments evaporated.[ 25] But suppose the very real benefits of Pap tests and pelvic exams remained: these screenings continued to be lifesaving for tens of thousands of people. Would doctors therefore be justified in withholding oral contraceptives until patients undergo beneficial tests? I argue they would not. Even if no medical harms arose from limiting access to birth control, threats to the well‐being of patients would still persist.
Requiring medical interventions, even if they are for the patient's own good, is not within the realm of doctor choice. Doctors can make recommendations, but they cannot permissibly use coercive tactics to gain compliance. Paternalism in the medical realm is a danger to patients and doctors should be careful about imposing their own conceptions of the good on their patients. When a patient engages in informed refusal, appropriate responses include clearly documenting the refusal and raising the issue again, but not withholding care. Paternalism was once standard in the medical profession because doctors saw themselves as being in a better position to decide what is best for the patient than those patients themselves. Now, it is a holdover from a different era.[ 26]
Consent
Informed consent is a crucial tenet of medical ethics. Maintaining patient consent is a key component of a successful medical practice. Consent has several features: patients must be fully informed and understand the risks and benefits of a treatment; they must be competent to make the decision; and they must make the choice voluntarily.[ 27] This last condition requires that the consent not be under duress. Duress can take many forms, including the limiting of options. For example, a criminal who threatens your money or your life is technically giving you a choice, but your decision to hand over your money could be not be construed as consensual because such a decision was made under duress and with limited options. Withholding contraceptives to force a specific test violates consent because it takes away a treatment the doctor and patient have jointly decided is necessary and limits options to achieve compliance.[ 28]
Additionally, requiring a Pap test for a birth control prescription spreads misinformation about birth control. For example, it suggests that it is unsafe to take birth control without such tests. The practice may also lead patients to believe that they need yearly Pap tests. When patients believe these measures are necessary, they may make tradeoffs in their overall health considerations that are a net loss to them.
In fact, the practice spreads the misinformation that knowing whether one has cervical cancer is more important than the conditions that hormonal birth control treats. When patients believe this fiction, they operate on the assumption that birth control is much less important to their health than it actually is, and that cancer screenings are much more important to their health than they actually are. These skewed priorities that doctors endorse can lead to poor decision‐making in the future and undermine informed consent.
Lastly, informed consent to a medical intervention requires understanding the risks. Doctors are not likely to spell out the risks of Pap tests when they are so adamant that their patients get them. They are even less likely to inform their patients of the added risks of getting Pap tests more often than the medical discipline recommends, such as the higher likelihood of false positives and the ensuing harms of overtreatment. Would doctors requiring yearly Pap tests be inclined to tell their patients that Pap tests are only recommended every three to five years for most patients and that getting the test more often causes increased harm? Would so many patients undergo yearly tests if they knew that yearly testing lacked supporting evidence? The evidence suggests not. Having truly informed patients would undermine their personal goals, while keeping patients in the dark would better suit their values. Nothing about the practice of tying birth control to Pap tests rules out this forthrightness on the part of doctors, meaning the consent is not necessarily uninformed. But it is more likely to be uninformed.[ 29]
EXPLANATIONS OF CURRENT PRACTICES: SEXISM IN THE FIELD OF OB/GYN
Financial exploitation is a simple explanation of current practices. Doctors clearly benefit monetarily from a yearly visits, since it puts money in their pockets and makes them more necessary to patients. However, exploitation does not sufficiently explain this phenomenon, because this phenomenon is not equally spread out in different areas of the profession. For example, we do not commonly see dermatologists withholding acne medication until their patients get cancer screenings. Other things being equal, while women's choices are commonly disregarded in OB/Gyn contexts, similar practices are less common in doctor's policies toward cisgender men. It is not only illegal for doctors to withhold needed medical care to men, but also rare, even when they are acting in their patients’ best interests.[ 30]
In addition, no evidence suggests insurance companies make the same calculations to exploit female patients for financial gain. First, the Affordable Care Act mandates Pap tests, pelvic exams, and contraception itself to be covered. Since no copays are required, insurance companies have no expected gains from these tests besides the longterm benefit of healthier patients, which yearly testing does not support. Second, the ACA mandates that women not be charged more than men for health care. Prior to its implementation, women paid 50–80% more than men in health insurance premiums due to the expectation that they would use the health insurance more. But if health insurance companies interpreted more reliance on health insurance meant more expenses, then they would not have any incentive to force women to use health insurance more than they need. Third, pregnancy, birth, and dependents all can cause great expenses for health insurance companies. Insurance companies have a vested interest in avoiding unwanted pregnancies for their customers, which means that obstacles to procuring contraception are not financially incentivized.
Sexism is a better explanation of the practice because such practices are endemic in women's health. Obstetrics and Gynecology is a domain of the medical field rife with sexist behavior on the part of doctors, as evidenced by women's lack of control in birth and labor choices. Since we find no systematic evidence denying men choice in medical contexts, this asymmetry provides evidence of the role sexism plays in physician policies on women's health. Furthermore, it sheds light on other paternalistic practices in the profession. In several areas of health primarily affecting women, such as the morning after pill,[ 31] abortion,[ 32] C‐sections,[ 33] VBACs,[ 34] and birthing decisions,[ 35] doctors also routinely override patient preference.[ 36] In these cases, doctors often appeal to the health and needs of the fetus. However, their similar actions in the case of contraception, where no other moral person can rationalize their behavior, belie what is really going on. Paternalistic attitudes are found where doctors do not think their patients fit to make decisions or as full agents – many are more willing to accept paternalism towards children.[ 37] Infantilization of and sexism towards female patients is a better explanation for this widespread practice.
NEGATIVE HEALTH OUTCOMES OF LIMITED ACCESS TO BIRTH CONTORL: CURRENT PRACTICES VIOLATE ...
Pelvic exams are a necessary component of complete healthcare. They serve as an early warning detector for cancers, sexually transmitted diseases, infections, fibroids, and cysts.[ 38] Pap tests, which are one component of pelvic exams, screen for cervical cancer, a life‐threatening cancer which can be wholly circumvented by routine examinations.[ 39] Among patients who get checked regularly, Pap tests reduce mortality by 99%.[ 40] Since virtually all cervical cancers are caused by certain strains of the human papillomavirus (HPV), HPV tests are often included in pelvic exams as well.[ 41] Denial of these exams would constitute a real harm to patients.
On the other hand, just because a test is beneficial does not mean it is beneficial at any frequency. If a yearly checkup is helpful, it does not follow that twice‐yearly checkups are twice as helpful. As with any prophylactic measures, evidence‐based medicine tells us that screenings are most helpful at specific intervals.[ 42] Pap tests are recommended every 3 years for patients 21 to 29 years old, every 5 years for patients 30 to 64 years old if combined with HPV testing, and may be discontinued in patients over 65 years old.[ 43] In all cases, more frequent Pap tests are recommended if abnormal results occur.[ 44] The Center for Disease Control,[ 45] The American Congress of Obstetricians and Gynecologists,[ 46] the American College of Physicians,[ 47] the U.S. Preventative Services Task force,[ 48] The American Cancer Society,[ 49] The American Society for Colposcopy and Cervical Pathology,[ 50] and the American Society for Clinical Pathology[ 51] are among the many organizations that recommend against screening every year as the default practice.
Despite being lifesaving measures, Pap tests can also cause significant harms if given too frequently to patients who do not need them. Harms associated with the practice include: over treatment, breaks in continuity of treatment, temporarily untreated conditions, and elimination of long‐term use. I take each in turn.
The harms from too many tests include: ‘overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain, and discomfort.’ [ 52] The most common harm is unnecessary surgery, but distress is a non‐negligible harm also associated with the extra examinations.[ 53] Follow up procedures include biopsy, colposcopy, and even hysterectomy, all of which are painful, time‐consuming, costly, stressful, can lead to more false positives, not to mention the risks that go along with any surgical procedure and use of anesthesia.[ 54] Infertility, risk of preterm labor and cervical insufficiency are other harms from over treatment.
In addition to harms from overtreatment, going on and off birth control causes harms to patients. While some risks like nausea, vomiting, mood swings, spotting, cramping, and headaches are extremely common, others like ovarian cysts are unlikely. But hormonal shifts caused by going on and off the pill actually make pregnancy more likely while the body adjusts to its changing environment. That means that the patients most desirous of preventing an unwanted pregnancy are actually more likely to have one.
Pregnancy prevention is a crucial component of reproductive health. Not only are condoms less effective than the pill in actual use, but also the person subject to pregnancy controls the pill, adding a further benefit, and it is not time of need, making access particularly important for many. Pregnancy is a relatively dangerous condition, especially in the United States, which has the highest rate of maternal mortality in the developed world and is on the rise.[ 55] From preeclampsia to gestational diabetes, pregnancy brings with it a series of dangerous conditions that can negatively impact health in the short and long term. Intimate partners also pose a serious risk to pregnant people. Domestic abuse, already responsible for an estimated 20% of hospital visits by women, often increases or even starts during pregnancy. Poverty is another serious consideration attending unwanted pregnancy and childbirth.
Furthermore, more than half (58%) of people who rely on the pill use it for other health benefits besides contraception. The pill is an effective treatment for endometriosis, which can cause pain and infertility. The pill also treats the symptoms of polycystic ovarian syndrome (PCOS), endometrial hyperplasia, hypogonadism, PMS, acne, and irregular periods. Ironically, the pill also prevents a variety of cancers. It can cut the risk of endometrial and ovarian cancer by 70% if taken for an extended number of years.[ 56] By withholding the pill to gain compliance with cancer screenings, doctors are thus increasing patient risks of cancer. Harms in going off the pill demonstrate that even if no negative health outcomes attended unnecessary pelvic exams and Pap tests, the practice of withholding birth control in service of these examinations would still be questionable.
The view that yearly pelvic exams are unnecessary is gaining traction in the literature.[ 57] A consensus has emerged that the negative health outcomes are significant and thus that doctors should not require the tests.[ 58] Nevertheless, doctors have long known that withholding birth control is harmful to their patients. It is the need for birth control and the pain and stress that attends not having access to it that doctors rely on when they require Pap tests for prescriptions. If they did not choose to withhold medical care desired by their patients, their goals at increasing Pap tests would not be very effective.
Furthermore, the ‘tit‐for‐tat’ practice of offering birth control in exchange for a Pap tests underscores the legitimacy and need for the contraceptive itself. Patients cannot demand drugs from their doctors. But doctors do not usually engage in such practices to release other drugs. Undergoing a needed biopsy would not be sufficient for a dermatologist to prescribe opiates if the opiates were not medically necessary and not related to the biopsy, even if the patient very much wanted them. If the patient wants opiates, doctors do not say ‘you can have them as long as you get that mole checked out.’ Either the opiates are necessary, in which case the doctor prescribes them without the biopsy, or the opiates are not necessary, in which case the doctor does not prescribe them even with the biopsy. The tying of the drug to the medical procedure shows that the doctor finds the drug itself a permissible or necessary medical intervention. Thus, while recent changes have rightly stressed that unnecessary harm is a reason to end the practice, consensus on the harm itself has likely been long‐standing.
I have already catalogued the numerous health problems that arise from too many Pap tests. However, the underlying reason for Pap tests – early cervical cancer detection – is increasingly outdated technologically, since we have a good vaccine for it, even if it is not outdated in reality due to low compliance. Gardasil is an HPV vaccination recommended for ages 11–26 for women, 11–21 for men who have sex with women, 11–26 for men who have sex with men, and up to age 26 for men who are immuno‐compromised.[ 59] While HPV causes a variety of cancers in both men and women, it is the main cause of cervical cancer in women. The vaccine has had large impacts, even with relatively low rates of the population in compliance. For example, after vaccine programs, “… as successive birth cohorts began cervical screening, reductions as high as approximately 45% in low‐grade cytological abnormalities and approximately 85% in high‐grade histologically confirmed cervical lesions became apparent.” [ 60] For patients who have not received the vaccine, and until a sufficient number of patients are vaccinated for the disease to create herd immunity, Pap tests will still be necessary. But in today's climate, asking patients to undergo a Pap test to give them birth control should be like asking them to take a polio test before setting a broken ankle. Polio should not be a threat because we have an effective vaccine for it, and setting a broken ankle should not be conditional. Gardasil has been around for more than a decade, and it is increasingly absurd to continue testing for a disease every year when doctors could instead recommend a vaccination that effectively prevents it.[ 61]
Current practices clearly violate physician dictates and the Hippocratic Oath to first, do no harm. However, I argue that even if no harms occurred from these tests, they would still be unjustified. In fact, too much emphasis on the medical harms done by these requirements overlook arguably more important and more fundamental protections for patients. Failure to prescribe birth control – even if yearly Pap tests did not pose considerable risks – constitutes negligence and disrespect for the patient.
LEGAL PROBLEMS WITH DENYING PATIENTS ACCESS TO BIRTH CONTROL: NEGLIGENCE AND MALPRACTICE
In discussions of medical malpractice, ‘The injured patient must show that the physician acted negligently in rendering care, and that such negligence resulted in injury. To do so, four legal elements must be proven: ( 1) a professional duty owed to the patient; ( 2) breach of such duty; ( 3) injury caused by the breach; and ( 4) resulting damages.’ [ 62] All four conditions are easily met.
In this context, physicians and patients have already worked together to find a birth control method that works for them. Physicians have already recommended the use of this birth control for the treatment of a variety of issues. Patients have already commenced treatment. Any later changes mean the interruption or halting of a needed medical interventional already in progress. In such cases, a doctor making a decision to stop medical treatment on behalf of patients, without patients’ consent or against their express wishes, for reasons entirely external to the issue at hand, constitutes negligence or medical malpractice. For example, suppose a man is at high risk for prostate cancer, has a long family history of the disease and is currently presenting symptoms.[ 63] It is in his own interest to receive a screening immediately, and his doctor tells him so. May the doctor discontinue the patient's dialysis to ensure compliance with the exam? We would classify the discontinuation of dialysis as negligence. As necessary as the prostate exam may be, it has no bearing on the patient's kidney failure. Both medical interventions are necessary and one should not be used as a carrot or a stick.
The second condition, the breaching of the duty is met when the doctor fails to prescribe the birth control. A breach of duty is generally determined by what is called the ‘standard of care’. A standard of care is established by what a reasonable professional in similar circumstances would do.[ 64] This test ensures the medical field itself determines the standard of care, making negligence a self‐regulating legal standard.[ 65] As noted above, standard of care is first, not to require yearly Pap tests and second, not to tie birth control to such screenings.[ 66] In this case, the universal recommendations in the field discussed above clearly explain what a reasonable professional would do when presented with a patient seeking a birth control prescription renewal.[ 67]
The injury and damages that follow are also discussed above. In many, though not necessarily all cases, denying patients needed medical care results in both injury and damages. Thus, the decision to withhold birth control is not merely an issue of office policy or personal philosophy; 85% of doctors actually meet the definition of malpractice.[ 68] That suggests a systemic issue.
CONCLUSION
In this article, I argued that sexism explains a widespread and systemic problem in the medical field and that doctors deny their patients needed medical care for no discernible medical reason. This explanation sheds light on a variety of crucial issues on the medical field. Only by grappling with the real reasons for physician behavior and calling sexism out for what it is can we improve reproductive health, health care for women, and work towards eliminating sexism in the field.
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