By Rachael England, John Stanfield and Gillian Cliffe

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On International Women's Day 2020 [8 March] a call was made to the British Dental Association (BDA) to address gender inequality amongst dentists.1 This article explores the variations amongst dental registrants and considers whether these variations are due to gendered, structural inequities and if so, to consider the impacts on female work experiences and career progression.

Today, women make up 77% of the UK dental workforce: 50% of dentists and 92% of dental care professionals (DCPs).2 The authors argue that this is due to prevailing gendered inequities and expectations that men are likely to be dental technicians and women dental nurses, dental hygienists and dental therapists (Table 1).

Table 1 General Dental Council registrations by type - March 20202
Full size table

The male DCP perspective

We argue that these gender inequalities are problematic for all of us and pose problems for men who wish to pursue non-traditional roles. Much has been researched and written about the equality and diversity of women in the workplace, or more so about the lack of it. However, an area that has been under-researched is that of the experiences of men in a female-dominated part of dentistry. Of the DCPs on the register, 8% overall identify as male.2

Men entering a female-dominated work environment challenge attitudes and upset the gender assumptions founded in historically male/female roles.3 They can experience discrimination in the hiring process3 and can feel a need to adapt their own behaviours to fit into this new role. Researchers have explored these issues in other female-dominated occupations4,5,6 such as nursing and primary school teachers. Findings show that discrimination exists between genders in both directions.6 Men working in non-traditional roles are also assumed to adopt leadership positions.3 One of the authors has frequently been assumed by others (for example at conferences) to be a dentist, with the contributors visibly shocked when corrected that he is a dental hygienist.

Possible barriers to DCP career progression

We argue that these structural and social inequalities affect female career progression. The role of DCPs has evolved over the decades. Due to numerous policy changes, they can hold more positions of responsibility and leadership. For example, since 2013, patients have been able to access the services of DCPs (dental hygienists, dental therapists and clinical dental technicians) directly, without the need for the prescription of a dentist. Additionally, dental nurses have been able to participate in oral health programmes.7

DCPs may now find themselves in a wide variety of roles, from implementing oral health programmes, to senior NHS leadership roles, such as Donna Hough who is the first DCP to be appointed as a postgraduate Dean for Health Education England. Attaining these roles requires the time and resources to develop additional skills. However, we argue that women are more likely to have competing priorities in the home which pose significant barriers to further education and extra-curricular activities.

The United Nations estimates that women carry out 2.5 times more unpaid work such as caring (for children and/or elderly relatives), cooking and cleaning, leaving less time for full-time employment, further education and self-development.8 The financial investment required is an additional barrier for the female workforce from furthering their education and adopting leadership roles. For example, the average cost of a Master's degree in the United Kingdom is £7,9469 and the average salary for a dental hygienist starts from £23,023 working for the National Health Service10 and £48,285 in private practice.11

Expectations of a woman's role may also pose barriers to pursuing 'non-female' roles. Gendered ways of knowing are found in culture, language and education.12 Examples include boys' and girls' clothes and toys, or children's books and advertising practices.13 Consequently, gendered social practices seem natural, rather than socially constructed.

It is essential that the workforce develops as highlighted by The Centre for Workforce Intelligence report commissioned by Health Education England to forecast the supply and demand for DCPs between 2013-2025. They stated the importance of skill mix in meeting the oral health needs of an ageing population and the extreme burden of caries in children, adopting up to 50% of the workload by 2025, as opposed to the 20% today. With the NHS England redeployment strategy of oral health professionals to deal with the COVID-19 crisis, we have seen all members of the team appointed equally, with both dentists and DCPs assigned to roles such as record taking, patient comfort and housekeeping duties - all essential to the running of the emergency response - suggesting the hierarchical nature of dentistry is largely arbitrary.

Men entering a female-dominated work environment challenge attitudes and upset the gender assumptions founded in historically male/female roles.

In September 2019 Greta Thunberg, aged 16, stood in front of the United Nations and delivered a speech that reverberated around the world. 'How dare you,' she roared. 'How dare you look away… and come here saying that you're doing enough'. Immediately she was verbally attacked and disparaged by men in positions of power, including the President of the United States, labelling her as 'emotional and hysterical', stereotypical labels used to undermine the female authority and silence them.14 Later the same year, recognising that sexism is deeply ingrained in our society,8 the Advertising Standards Authority introduced a code of practice aimed at tackling it by banning advertisements that use sex to sell, for example innuendos, sexual objectification and explicit content.

As DCP professions are generally dominated by females this would possibly give evidence to the gender inequality that is overtly present in our profession and that of other healthcare professions. Zosuls et al. (2011) also propose that early development in gender roles and discrimination and stereotyping is already entrenched by the time we reach adulthood.15 Could it then be argued that our early years' socialisation has already paved the way for preconceived ideas on gender roles and hierarchy, to professional roles and leadership roles being part of this?

Despite the value and importance of the DCP female workforce as evident by the COVID-19 response, DCP testaments suggest that they are not valued, and experience harassment and micro-aggressions as studies show approximately 50% of female DCPs have experienced sexual harassment by male dentists and patients.4,16 Micro-aggressions are 'subtle, often automatic and nonverbal exchanges which are put-downs'.11 They reinforce the belief that women are inferior to men, reduce women to mere objects and invalidate the feelings and opinions of women. Examples include sexual innuendo, sexist jokes and comments on a woman's appearance.17 DCPs have reported numerous experiences of micro-aggressions from male colleagues or patients.11 Examples of micro-aggressions suffered by female DCPs uncovered by the author include the following:

'He was like, "Wow!" He was like, "You did a great job. You look really good for having three kids." I mean, it hurt my feelings a little bit because it, there was just this underlying insult, you know? A compliment, but also an insult [laughs] at the same time!

'And I feel like he didn't like to hire male staff members because, I think he liked the control he felt like he had over women.'

Despite the often vague and off-handedness of micro-aggressions, their impact is no less damaging and can have chronic long-term effects on the recipient and can elicit harmful coping mechanisms. Although blatant discrimination is generally declining, inequalities in the workplace are manifesting in more ambiguous ways, therefore, a change to the traditional systemic structure of the profession is required for DCPs to gain greater autonomy.17

Conclusion

As stated by Lala and Thompson (2020) the dental profession has a long way to go towards providing inclusive environments,1 equity and protecting the rights of all oral health professionals. The authors of this article call for further research to understand the effect of hegemonic masculinity across the dental profession.

Acknowledgements

With a special thank you to Wendy Thompson and Rizwana Lala for their invaluable advice and guidance.