(De)Gendering Older Patients: Exploring Views on Aging
and Older Patients in Romanian General Practitioners
Abstract. Purpose: Demographic changes make it necessary to improve communication with older patients and design
gender sensitive health promotion. The present article aimed to explore how general practitioners see old age and what
role gender may play in their representations of aging. It also looked whether the gender of the older patients played a
role for how general practitioners treated them. Methods: Episodic interviews were conducted with 17 women and 17 men
who worked as general practitioners in Romania. Thematic coding was used to analyze data. Results: Findings showed that
general practitioners saw old age as negative no matter their gender. Older patients were perceived as difficult and mostly
older women were given as negative examples to illustrate treatment non-adherence and psychological or social problems
related to aging. Conclusion: Negative aging views combined with a (de)gendering of aging patients may lead to maintain
negative aging stereotypes and gender inequality in old age. Implications for preventing this from happening are discussed.
Keywords. Aging views, active aging, general practitioners, gender, older patients.
Resumen. Propósito: Los cambios demográficos hacen necesario mejorar la comunicación con pacientes mayores y
diseñar promoción de la salud sensible al género. El presente artículo explora cómo médicos generales perciben la adultez
mayor y qué rol puede jugar el género en sus representaciones sobre el envejecimiento. También examina si el género de
los pacientes mayores jugó un rol en la forma en la que los médicos generales los trataron. Métodos: Se llevaron a cabo
entrevistas episódicas con 17 mujeres y 17 hombres que trabajaron como médicos generales en Rumanía. Se usó codificación
temática para analizar los datos. Resultados: Los hallazgos mostraron que los médicos generales ven la adultez mayor como
negativa sin importar el género. Se percibió a los pacientes mayores como difíciles y se mencionó principalmente a mujeres
como ejemplos negativos para ilustrar falta de adherencia al tratamiento y problemas psicológicos y sociales relacionados
con el envejecimiento. Conclusión: Ejemplos de envejecimiento negativo combinados con una invisibilización del género
de los pacientes puede guiar hacia el mantenimiento de estereotipos negativos sobre el envejecimiento y la desigualdad de
género en la adultez mayor. Se discuten implicaciones para prevenir que esto pase.
Palabras clave. Perspectivas de envejecimiento, envejecimiento active, médicos generales, género, pacientes mayores.
Actualidades en Psicología, 30(121), 2016, 1-9
http://revistas.ucr.ac.cr/index.php/actualidades
1
Dr. Catrinel Craciun. Babes-Bolyai University, Romania. Freie Universität Berlin, Faculty of Education and Psychology, Department of
Qualitative Social and Educational Research. Germany. Postal Address: Habelschwerdter Allee, 45 14195. Berlin Postal Address: E-mail:
craciunic@zedat.fu-berlin.de
Catrinel Craciun
1
Babes Bolyai University, Romania
Freie Universität Berlin, Germany
(In)visbilización del género: Explorando perspectivas sobre
envejecimiento y pacientes mayores en médicos generales rumanos
ISSN 2215-3535
DOI:
http://dx.doi.org/10.15517/ap.v30i121.24069
Esta obra está bajo una licencia de Creative Commons Reconocimiento-NoComercial-SinObraDerivada 4.0 Internacional.
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Actualidades en Psicología, 30(121), 2016, 1-9
Introduction
Demographic changes around the Globe increase the
need for health professionals to treat aging individuals
(Weicht, 2013). Medical treatment and communication
imply not only providing accurate medical advice, but
also transmitting ideas about positive aging (Craciun
& Flick, 2015) or gender sensitive advice in old age
(Reitinger & Beyer, 2010; Foster & Walker, 2014).
Nevertheless, active aging policy recommendations
(Lassen & Moreira, 2014) might not be easily integrated
in busy medical schedules and ideas about active aging
that might be accepted in Western contexts may not
be popular in Eastern European contexts (Craciun,
2016). Furthermore, older patients may be the target
of double stereotyping and discrimination in terms
of both age (Levy, 2003) and gender (Palència, 2014).
The present article seeks to add to existing literature
on aging representations in medical personnel (Liu,
Norman, While, 2013; Walter, Flick, Neuber, Fischer,
Hussein, Schwartz, 2010) and experiences of general
practitioners with older patients (Craciun & Flick, 2015;
Craciun, 2016; Flick, Garms-Homolova, Rönsch, 2012)
by exploring how the gender of general practitioners
plays a role in their aging representations and how they
perceive older women versus older men as patients.
Gender Equality in Health and Aging
Gender inequalities refer to the differences between
women and men that systematically empower one
group (usually men) to the disadvantage of the other
(usually women).
Gender equality represents an important human
right that is achieved when both women and men enjoy
the same rights and opportunities (UNDP, 2014). One
of these rights is being entitled to live a healthy old age
and enjoying quality of life no matter if one is a man or
a woman. Nevertheless, this might be more difficult for
women as compared to men, even if women are shown
to live on average longer lives (Austad, 2006). Economic
difficulties that emerge from the fact that women are
more likely to be employed in precarious jobs or to be
single mothers (Annandale & Hunt, 2000) may have an
influence on their quality of life in old age as compared
to that of men. Moreover, older women were shown
to act as caregivers for their ill husbands and to suffer
negative consequences for their mental and physical
health (Schrank et al., 2016). Previous studies reported
a gender related disparity in health with either women
(Caroli & Weber-Baghdiguian, 2016) or men (Lipsky,
Cannon, Lutfiyya, 2014) at disadvantage concerning
health in old age (Bird & Ricker, 2008). Furthermore,
aging itself might be experienced in different ways
according to one’s gender (Connell, 2012). Gendered
access to health care and health problems accumulating
over the lifespan might contribute to gender inequalities
in old age. In addition, even health care systems
themselves, through the ways they are organized, may
contribute to emerging and sustaining gender health
inequalities (Mackintosh, 2000). Being an older woman
might be more difficult than being an older man, and
inequality might emerge from the way women and men
see their aging as well as how they are seen by others
in the society.
Health professionals and aging representations
Active aging policy means ensuring that older
citizens have the right to live a happy, independent
old age (Lassen & Moreira, 2014). It focuses on their
healthy lifestyles or on building structures that allow
for a positive old age. The present article focuses on
the latter in terms of health professionals and their role
in healthy aging. General practitioners (GPs) represent
the key workers in many health systems. GPs are the
ones who have contact with people over the lifetime,
and can offer lifestyle advice. GPs views on aging are
relevant since they might unknowingly maintain certain
negative aging stereotypes by promoting negative
images of aging in their work. A positive view of aging
means that they see the potential for development
and experiencing positive emotions in old age, while
negative images of aging mean associating old age with
illness and dependency (Levy, 2003; Wurm, Tomasik,
& Tesch-Römer, 2010). Previous studies showed that
health professionals had more negative images of aging
(Walter et al, 2010; Craciun & Flick, 2015; Craciun,
2016). The present study wants to go further and
explore whether GPs treat men and women differently
(De)Gendering Older Patients
Actualidades en Psicología, 30(121), 2016, 1-9
3
in their practice and whether their representations of
older patients are gendered.
Gender may play a role in how GPs relate to aging
for several reasons. First, the representation of aging
women was shown to be more negative than that of
aging men (Smirnova, 2012; Craciun & Flick, in press).
Thus, when interacting with patients, GPs may be
affected by the social representation of aging women or
men or they might use their own aging representation
and project it on their patients. For example, they might
be more caring to older women patients because they
believe that older women need more help as compared
to aging men. Since Romanian men go less to a doctor
(Titan & Otoiu, 2014), the ones that do visit the GP
may be more adherent to treatment and could be given
as positive examples. Nevertheless, if the GPs are men,
they might hold a negative view of their own aging
process and use it to evaluate their aging men patients.
Present findings should help shed light on this issue.
Aging in Romania
There older population in Romania is on the rise, with
around 15% of the population being over 65 in 2010
and expected to increase to 30% by 2050 (Asandului,
2013; Bodogai & Cutler, 2013). Health inequalities for
Romanian pensioners are a reality since their financial
situation is below that of other EU countries and
economic resources are insufficient for supporting
a growing number of older individuals (Bodogai &
Cutler, 2013). Thus, financial independence in old
age as active aging policies (Lassen & Moreira, 2014)
envision may be more difficult to reach. Moreover,
previous studies have shown that older Romanians (i.e.
older than 65) have negative representations of aging
(Craciun, 2011), and consider they had few resources
to reach a positive old age (Craciun, 2012). Pensions
are known to be on average around the equivalent of
225$, representing 50% of the net average wage, and
being far below the living expenses needs (Bodogai &
Cutler, 2013). Since the proportion of older women
(59%) is higher than that of older men (41%), there
may be also a higher probability for older women to
be at a disadvantage in terms of reaching active aging
policy goals.
General practitioners (GPs) may play an important
role since older individuals were shown to visit a
doctor frequently (Titan & Otoiu, 2014). For instance,
it was shown that as people age, they need more
health care services. The proportion of Romanians
older than 65 who went to a GP in the last 4 months
reached 31.7% (Titan & Otoiu, 2014). GPs represent
the gate keepers within the Romanian health system,
and older individuals cannot benefit from specialist
consultations or medicine at reduced price without a
recommendation from the general practitioner. In a
previous study, it was shown that Romanian doctors
have negative views of old age and older persons
(Craciun, 2016). This study goes further to investigate
whether representations of aging differ between female
and male GPs and whether they are treating gender
differently concerning aging male and female patients.
Gender inequalities might emerge or be strengthened
from being treated differently by a GP.
Aims
The present article explored whether women doctors
represent old age differently from men doctors in the
context of the Romanian health system. Moreover, it
aimed to explore if Romanian general practitioners
represent and act in different ways towards male and
female older patients.
Methods
Sample
A number of 34 interviews were conducted with
Romanian general practitioners. The sample comprised
17 women and 17 men, with ages ranging from 30 to 60
years old. Inclusion criteria were (1) having worked or
to be working with patients who are older than 65, (2)
medical practice experience of at least three years and
(3) to be working in a public clinic or private practice.
Snowballing technique was used for participants’
recruitment. All participants were informed about the
study aims and signed consent forms regarding their
participation. Confidentiality and anonymity were
guaranteed to all study participants. Ethical aspects of
the study were approved by the ethical board of the
Babes Bolyai University in Cluj Napoca.
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Data Collection
Episodic interviews (Flick, 2014) were carried
out in order to collect data. The basic assumption
for episodic interviews is that people encode and
retrieve information in form of semantic and
episodic knowledge. Semantic knowledge refers to
concepts and relations between these, as for instance
the concept of old age and its relation to health.
Episodic knowledge describes the context where we
have learned the semantic contexts are learned. For
instance, in the case of the present study this would
be the medical everyday context where GPs meet
their patients and offer medical advice. The interview
guide comprised nine questions including topics such
as what is the GPs experience with older adults as
patients, how they would describe an older patient as
compared to younger ones, how they perceive aging
(“what does aging mean to you?”), how they perceive
female versus male patients. Interviews took around
40 minutes to complete and were carried out at the
hospitals or medical practices where the GPs worked.
All interviews were transcribed verbatim for the
purpose of analysis.
Data Analysis
Data analysis was performed with thematic coding
(Flick, 2014). This method was chosen as it was proven
effective in case of comparative studies where the
groups under study have already been defined within
the research question (Flick, 2014; Flick et al, 2012).
The underlying assumption is that differing views can
be found in different social groups concerning the
same topic that makes the subject of research. Patterns
of interpretations and practice were identified within
the statements of the professionals. All interviews
were first analyzed as a series of case studies (i.e. all
interviews) and all statements were coded for thematic
areas (e.g. Representations of aging) and for each
case (each single interview). In a second step of the
analysis, comparative dimensions were identified for
each case. They were used as a starting point to identify
common aspects and differences between interviews.
Based on these dimensions and their features the cases
were classified and analyzed for specific combinations
of features. For instance, the analysis focused on how
female and male GPs represented aging and how they
performed gender in their practice of treating older
women and men. Similarities and differences between
female and male GPs were identified in order to identify
typologies of patterns of interpretations and practices
which were then analyzed in terms of their contexts
of meaning following the model of previous research
(Craciun & Flick, 2015). The identified themes were
checked for reliability by two other research assistants.
The author conducted the analysis in Romanian with
the use of Atlas.ti software and translated selected
quotes into English for the purpose of this article.
Results
(De)Gendered representations of aging among GPs
Both female and male GPs represented old age as
being something negative. For instance, old age was
associated with illness, loneliness and dependency.
Old age is when you start depending on others,
you start forgetting things, you cannot take care of
yourself anymore, you forget your medicine, you
have no appetite, and you start thinking about death
and the life you had before (GP07, f, 38 years old).
The relevance of subjective age was emphasized,
especially the difference between chronological age
and actual age. However, this was done pointing that
one could already be ill and dependent in ones’ fifties
and not necessary only in ones’ seventies, not that one
could still be healthy and happy in ones’ eighties.
I believe you are old when your body is old, the
illness is so bad that it cannot fight anymore and no
medicine can help, not the age in years is relevant
(GO06, f, 57 years old).
When talking about ways in which to reach a
good old age, women GPs accentuated psychological
aspects such as being “at peace with yourself ”, getting rid
of negative emotions, the importance of socialization
and having a positive attitude towards young people.
Among the interviewed GPs, men mentioned an active
lifestyle or a positive state of mind as ways in which
one could reach old age. The greatest barriers for aging
well were considered to be the economic situation and
(De)Gendering Older Patients
Actualidades en Psicología, 30(121), 2016, 1-9
5
the state of the health care system, as described by all
interviewed GPs regardless of their gender.
(De) Gendered Representations and Actions towards
older patients
In what concerns how general practitioners perceived
their older patients, no differences emerged among
the interviewed women and men GPs. The common
theme was that of the difficult patient, regardless of
the patients’ gender. Cases of women patients were
chosen to illustrate negative aspects related to the aging
population such as their vulnerability and dependence.
The “difficult” patient
Both older women and men were described as
being “difficult” patients. Being difficult, meant that
for instance, an older patient would not understand
medical advice. Moreover, even if patients understood
the medical terminology, they would not comply with
medical recommendations. The interviewed GPs
believed that making lifestyle changes in one’s old age
was very difficult since they believed older people are
not open to change and learn new things with difficulty,
as one participant pointed out:
In case of patients who are older than 65 I have to
repeat the medical information several times, how to
take the medicine for instance...they usually always
say yes and nod as if they had understood but in the
end I have to talk to their children to make sure they
do what I advised (GP06, m, 36).
In addition to not being able to grasp what the doctors
recommend, difficult patients were also described as
being rude and uncooperative, and even sometimes
threatening as another participant mentioned:
I am bothered by the ones who don’t pay attention
and are rude, they use bad language, they display a
superiority attitude, they threaten they will complain
to the authorities. I just ignore them, there is no use
talking to them. After all these work experience, I
know I do not need to bother too much with them.
They have their own worries and will not understand
what I want to tell them (GP03, f, 46).
Despite the negative depiction of the older patients’
behavior, the GP in the example above displayed an
understanding attitude towards the difficulties that
older patients face in their daily lived lives, and that
may make them seem unfriendly in the medical context
where they are stressed.
Difficult patients were also described as older
individuals who are not adherent to treatment because
they forget to take medicine as a “normal” characteristic
of old age. Since they did not understand the treatment
program and effects, old people were considered
“irresponsible” or were described as depending on
other adults to take care of them and bring them to the
GP when medical symptoms occur:
For instance this old lady, she takes her medicine a
few days, than she sees she does not feel good, than
she stops taking her medicine. Than when she gets
sick, a neighbor brings her to me. I tell her that she
needs to take the medicine the whole long period
for it to have an effect, but she does not want to
understand. She says it doesn’t matter anymore,
she does not want to live, to be a burden for others
(GP02, f, 40).
In the example above, the “difficult” behavior of the
patient emerged from the difficulties of old age itself.
Older people were reluctant to medical advice since
they felt they hadve lived enough and did not want to
invest effort into getting better. There was no mention
of gender differences in how a GP should treat or
communicate with older patients or about tailoring
advice to men and women’s’ needs. Physical aspects
seemed to matter more when GPs spoke about female
patients; however, it could also be that older women
visit a doctor more frequently than older men do. For
instance, one male GP said old age can be recognized
by physical signs that were more important than
chronological age itself when estimating a persons’ age:
The other day two women came to my practice, I was
surprised to find out that the one with wrinkles and
bags under her eyes was the daughter of the other
one whose appearance did not show her age. Stress,
lack of sleep and smoking made the daughter look
older (GP10, m, 54).
Men were given as positive examples when GPs
talked about older patients who were adherent to
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Actualidades en Psicología, 30(121), 2016, 1-9
treatment despite difficulties. For instance, one GP
recounted a story about an older patient who used to
drink and smoke a lot, but after receiving the news that
he has diabetes, he started following the treatment and
the lifestyle changes:
I have never seen something like this before. That at
his age he could still become adherent to treatment,
but these cases are rare, one in a million.(GP02, f, 40
years old).
Women patients were often presented as negative
examples for treatment non-adherence. For instance,
one GP talked about a case where an older woman did
not understand the medical advice:
She just said yes to everything I told her, but she did
not understand, in the end she did not know what
she needed to do, so I had to talk to other child and
explain all to him again how his mother should take
the medicine (GP07, f, 38 years old).
Older women were also depicted as having
psychological problems such as depression or feelings
of resentment that interfered with their aging well:
I had this patient, this 75 year old woman, she was ill
and she had difficulties relating with others. She did
not get along with her daughter, she felt she was not
appreciated for her sacrifices, the efforts she invested
for her grandsons, and she could not forgive her
daughter for marrying without telling her, she had a
shock and just aged sooner (GP09, m, 37 years old).
All in all, GPs referred to older patients as
a homogenous group, characterized by illness,
poverty and loneliness. Poverty was presented as
the consequence of small pensions and high living
expenses, high costs of medicine included.
Loneliness was seen as the effect of families not
living together anymore, for instance children and
grandchildren living far from the older family members,
mostly in other countries. Women were given as an
example to illustrate how sometimes older patients
become social cases that need help more than in the
medical domain.
For instance, one GP recounted how he helped one
woman female patient find a job :
I usually have patients who are looking for a job.
This older lady came to me and asked if I could
recommend her to somebody that needed help with
their children because she is good with children and
could do such work. So I recommended her to a
family and now she has been working for 10 years by
this family, she has become part of the family herself
almost (GP15, m, 58 years old).
The above example may also be regarded as a success
story where an older woman found “a new” family and
meaning in old age.
Discussion
Images of aging and gender might placeut either
older women or older men at a disadvantage and
increase gender inequalities in old age. Present findings
lend support to previous literature showing that
medical personnel tends to have rather negative images
of old age (Walter et al., 2010; Craciun & Flick, 2015;
Craciun, 2016). Having a negative image of aging may
reflect on how they treat older patients and contribute
to the maintenance of negative stereotypes related to
old age (Craciun, 2016). Furthermore, even if the GPs
tried to promote a positive old age in their practice,
their own negative images of old age might constitute
a relevant barrier in this endeavor (Craciun & Flick,
2015). The association between old age and illness
might be particularly dangerous in case of medical
personnel. On the one hand, previous research has
shown that in order to have a positive view of aging
one should dissociate old age from illness (Wurm
et al. 2010). On the other hand, previous findings
showed negative images of aging become self-fulfilling
prophecies (Wurm, Warner, Ziegelmann, Wolff,
Schüz, 2013). Thus, if medical doctors hold negative
images of aging, they are at risk themselves for lower
longevity and lower quality of life in old age (Levy,
2003). Furthermore, they may transmit the negative
image of aging to their patients or develop a negative
attitude towards elderly patients based on such negative
aging views. Nevertheless, the image of the “difficult
patient” may be also interpreted as a realistic view of
the difficulties faced by older patients in their daily
lives. Although it may reflect a negative view of old
(De)Gendering Older Patients
Actualidades en Psicología, 30(121), 2016, 1-9
7
age, it does not automatically translate into a negative
attitude towards older people and patients in particular.
On the contrary, some GPs displayed an emphatic
attitude by showing that they understand the difficult
circumstances of their older patients. In practice,
GPs should help their patients interpret symptoms as
caused by certain medical problems like diabetes or
high blood pressure and not by old age itself and help
them deal with those symptoms by taking medicine or
making lifestyle changes. All in all, findings pointed out
that both male and female GPs displayed a negative
representation of old age, although in the existing
literature women seem more prone to have a negative
representation of old age (Smirnova, 2012; Craciun &
Flick, in press).
In what concerned the second research question,
findings showed that GPs saw both older women and
men as vulnerable patients. The fact that older women
were given as examples to illustrate the bad condition
of the “Romanian old person” could mean that there
are more negative representations of ill or needy older
women and these representations were therefore easier
accessed and activated. It may also mean that “being
dependent” and “weak” were seen as rather feminine
traits and that older men were also invested with these
feminine qualities and treated as part of the same group
of “difficult” older patients. Nevertheless, it could also
be that more examples of women are provided since
Romanian women are known to visit doctors more
often as compared to men (Titan & Otoiu, 2014).
The fact that no particular gender differences
emerged in how GPs perceive older patients may also
be interpreted as suggested by another study, that
a degendering of older people (Silver, 2003), in this
case older patients, takes place. Treating older patients
as a homogeneous, a “degendered” group, does not
automatically mean that older women and men are
treated equally in terms of their rights to good health
care and information about positive aging. It may mean
that gender issues are not considered that relevant or
are not addressed specifically in the medical context
since health is human right, not depending on gender.
However, the fact that older patients get treated like
a homogeneous group leaves space for negative aging
stereotyping to strive (Levy, 2003). Focusing on negative
examples, may make the negative age stereotype
stronger. Moreover, for some of the interviewed GPs
even if the age difference with the patients they talk
about is not that big (i.e. between 5 and 15 years), they
described the older patients as belonging to a totally
different age group with limited opportunities for
growing old in an active or dignified way. This could
mean that the interviewees attempted to distance
themselves from the patients they were dealing with,
not acknowledging the fact that they could someday
become aging patients themselves.
Present findings should be expanded with
quantitative studies on how negative versus positive
representations of aging in GPs influence their actions
in practice and the views on aging of their patients.
Furthermore, the views of health professionals and
patients alike are relevant. For example, even if the
views of GPs go into the direction of active aging
and gender equality, there might be differences in what
concerns how their aging patients understand these
issues. Thus, the views of the patients may be explored
in a future study and contrasted with the views of the
GPs on topics such as aging, health and gender. The
present study represents a first step in the direction
of showing why some active aging policy principles
as well as gender equality issues could be still difficult
to implement in the Romanian health system and how
gender inequalities might be sustained involuntarily.
Future studies should also look at how interventions
may be developed and tested for effectiveness in what
concerns changing negative views of aging among GPs
and helping them adopt more gender sensitive health
communication with their older patients.
The first step towards effective interventions would
be that GPs would believe in a positive old age, and
second they would implement active aging ideas in their
work. As pointed out in a previous study, GPs should
increase their self-efficacy towards implementing active
aging policy (Craciun, 2016). Moreover, GPs should be
sensitive to gender differences (Foster & Walker, 2014)
and adapt their discourse and treatment advice to the
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Actualidades en Psicología, 30(121), 2016, 1-9
needs of older women and men. Sense of control was
shown to be important for life satisfaction in old age
(Wiest, Schüz, Wurm, 2012) and GPs might try to develop
this for their older patients in order to improve the
quality of life. As an important implication for practice,
health communication workshops for GPs should
be organized to address issues such as acknowledging
gender differences between aging women and men,
but deceasing gender inequality among older patients.
This may represent a step forward towards tackle
health inequalities as well as gender inequalities among
Romanian pensioners in particular, but also between
countries in what concerns implementing active aging
policies (Lassen & Moreira, 2014) and gender equality
policies (Palència et al., 2014).
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Received: May 1
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Accepted: September 7
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2016
