The Impact of the “Empathy Tax” on Women Physicians
Illustration: Content designed by Helen J Butlin, PhD, Artist: Martha Elliot, MSW, RSW
High empathy can leave physicians more vulnerable to poor mental health, especially when efforts to alleviate suffering inadvertently support a harmful system. In contrast, self-compassion builds resilience and helps prevent burnout but only when a historical consciousness and skilful critical reflexivity is embedded into your perceptions. You must also consider the socio-political-cultural issues that will be systemically embedded in the context in which you are practicing medicine and the specific situation, personal and professional, that you are struggling with.
Women physicians often face systemic gender bias and carry a heavy emotional and relational burden—an “empathy tax”—leading to burnout, lower pay, fewer promotions, a distorted sense of self, and worsened mental health. The physiological differences between empathic distress and compassion are important to recognize and to understand how practices like Mindful Self-Compassion and Polyvagal Therapy can help buffer the empathy tax on your nervous system and well-being.
You don’t give yourself credit for how much you’re doing inside
Accelerated by the pandemic, physician well-being has been moving into focus in recent years. Prior to the pandemic, Singh et al. (2019) conducted a cross-sectional study involving 418 oncologists, revealing that 73% experienced burnout, with a significant factor being discomfort in discussing workplace stress with peers. More specifically, however, the wellness of women physicians has gained prominence in recent years. The 2018 Canadian Medical Association National Health Survey (NHS) reported a higher percentage of burnout, depression, and suicidal ideation by women physicians compared to men physicians. This difference was amplified, with increased percentage reporting across all three indices in the post COVID-19 pandemic 2021 National Health Survey.
This survey is cited and summarized in a March 2023 article on the Physician Wellness Hub titled, “Equity and Diversity In Medicine”, and the findings align with a study by Dillon et. al (2022), confirming the higher rates of burnout amongst women, younger clinicians’, and caregivers during the pandemic. Notably, pandemic constraints have intensified the dual burden of labour between work and home, with women facing increased responsibilities in childcare, children's education, and home management (Brown et al., 2021; Farid et al., 2024; Jones et al., 2020; Nishida et al., 2021; Ranasinghe & Zhou, 2023; Soares et al., 2021).
The Equity and Diversity article goes on to report on the many well-evidenced positive benefits to having and keeping women in their practice of medicine. It shows there is much work to do for keeping women physicians in practice across their careers.
The women in my practice and retreats have shown me that small, steady changes can lead to significant, long-term shifts in both personal and professional life. Depersonalizing the impact of structural, cultural, societal biases, and oppressions from a narrative believing “it’s me” has been a key for many clients for a truly meaningful internalization of self-compassion.
Socio-Political Context in Practicing Medicine for Women Physicians
Temken et. al. (2024) comment, “Physicians who are women, though present, have been folded into a rigid environment constructed without intent for them to thrive.” As such, if you are practicing medicine in Canada, regardless of your country of origin and cultural values, this is the inherited system you are practicing medicine within.
Daily, you are encountering systemic biases which include many systemic oppressions, explicit and covert, with one common denominator that if you are a woman, you are experiencing a gender bias from the outset of your medical training and across your career. Gender bias and outright gender-based systemic oppressions maintain barriers to professional and social rewards for anyone not fitting the medical culture shaped by and for the male. At the apex, the “ideal" white, male, Hero physician archetype exists. While physicians are also suffering in a breaking, perhaps already broken, Canadian health care system, women physicians are shown to be suffering in more numbers and enduring a wider variety of harms across their career trajectories (as indicated in the March 2023 article in the CME Wellness Hub, citing the survey conducted in the Canadian Federation of Women in Medicine). Recent studies foregrounding women physicians’ experiences underscore a persistent culture of patriarchy and misogyny, adding to the challenge of balancing professional demands with personal well-being (Carcador et.al., 2022, Rosenberg et.al., 2023, Temken et.al., 2024).
Problematizing “Wellness” Discourses in Physicians’ Lives
Wellness interventions can be problematic within the medical institution; teaching wellness without acknowledging the socio-political-cultural context can be not only ineffective but harmful. The concept of "wellness" in medical culture is tied to what Mark Fisher described as the "Privatization of Stress," which shifts the burden of well-being onto individuals while ignoring systemic barriers. This focus diverts attention from the need for collective solutions and structural change.
For physicians, this creates an extra burden: you must not only be a productive and perfect provider of medical care but also manage your own wellness without systemic environments holding a central value that your thriving is essential to your medical practice. Those who speak up and take action can experience being shut down and labelled as “the problem,” further reducing self-worth and significantly increasing the risk of a severe degradation of mental health. Mental health easily gathers stigma in your life and can seriously affect your career. This has been noted as starting in medical school with student’s fears of disclosing worsening mental health due to fear of stigma from peers and supervisors (Ng et al., 2024a). It remains along the career trajectory with the very real concerns about licensing and liability insurance reprisals should a mental health diagnosis be disclosed (Brower, 2021; Dyrbye et al., 2017; Mehta & Edwards, 2018; Ng et al., 2024b; Rátiva Hernández et al., 2023). Your need to get support is then disempowered, creating a culture of silence and isolated suffering, increasing your risk of serious harms.
When wellness practices fall short, it reinforces a sense of personal failure, amplifying feelings of blame and inadequacy in an inherently flawed system. This is the essence of structural oppression—internalizing the narratives fed to you about your worth and capabilities.
And this is why in my therapy practice and retreats, I emphasize an intervention using critical reflexivity in context of home and work life. This lens of critical reflexivity looks out into society and environments with structurally embedded barriers, oppressions, and biases to identify these harms that are implicated in eroding mental and physical well-being. Then a lens can be shifted inward for reclaiming personal agency. Changes can be made that pivot focus onto self-compassion for internalized shame, self-blame, and distress, which are caused or intensified by the systemic issues.
Holding a Historical Consciousness of Being A Woman Physician
The modern European-American-Canadian medical systems inherited a patriarchal-colonial legacy, with training and practices rooted in early European institutions. These institutions exiled, banished, and marginalized women and the Celtic and Indigenous knowledge systems across what has become Europe. Historically, until the 12th century, women healers in Celtic and other Indigenous communities were central figures, revered for their expertise. Minkowski (1992) wrote on these women’s roles being as central to community life as modern public health structures are now:
“European female healers of the Middle Ages performed a service virtually indistinguishable from the one so zealously cherished and aggressively defended by academically trained male physicians.”
However, in the 13th to 17th centuries, the rise of patriarchal control saw the violent persecution and extermination of women healers during the Inquisition across Europe and stripping all women of any rights and autonomy. As Eloise Loenen (2023) discusses in On Our Best Behaviour, this era also created a deep trauma fostering a climate of fear and division among women—a trauma of conquering, dividing, and causing women to turn on each other in competitive, ruthless work environments that is still prevalent in our cultural psyche and workplace dynamics. Many times, in retreats, sessions, and speaking engagements, I hear from women physicians that “women are the worst” when exercising leadership in power structures rooted in the patriarchal hierarchy. Competitive attitudes become the norm for survival.
By the 17th century, women in Europe had no public roles. The medical arts had evolved into structured learning in university centres across Europe, and women were completely excluded. Although as women you are now practicing medicine, patriarchal-colonialism is still embedded in modern health care systems that have adopted the training models and medical paradigm formed by the European institutions of medical training and delivery. This system has been globalized with curriculum and training exported throughout the world. As Temken et. al. (2024) comment, “Physicians who are women, though present, have been folded into a rigid environment constructed without intent for them to thrive.”
Regardless of your country of origin and cultural values, you are practicing medicine in an inherited system perpetuating the colonial-patriarchal values and ideology of medieval Europe. As such, you are regularly encountering systemic biases formed by the colonial-patriarchal historical and cultural paradigm, which includes racism, sexism, ableism, anti-queer, neurotypical bias, and fundamentally, white supremacy as an ideal. These prejudices are lived daily in impactfully harmful ways and maintain barriers to professional and social rewards for anyone not fitting the "ideal" white, male, Hero physician archetype.
Global Discrimination for Women Physicians
Gender discrimination is a worldwide problem for women physicians with numerous published studies from 2018–2024 reporting its impact across many countries where women are practicing medicine: Spain (Santucci, C., 2023), Japan (Kuwahara, H.,2023), India & Kenya (Saville, N. M, 2024), South Korea (Han, H., 2018), Egypt (Farahat, F. M., 2007), Brazil (Mainardi GM, 2018), Ecuador (Sarmiento Altamirano, D., 2021), Eastern Mediterranean region (Doraiswamy, S., 2021), and many more countries.
Throughout these countries, and likely many more, women physicians are performing significant interwoven and intractable amounts of unacknowledged and unbillable labour. This labour can be named as an “Empathy Tax.”
“Empathy Tax” in the Lives of Women Physicians
Illustrations: Designed in Canva by Martha Elliott
from a handout in Self-Compassion for Women Physician Retreats with Helen J Butlin, PhD
Implicit in any literature publishing data on gender discrimination is that women physicians are uniquely burdened by an invisible yet deeply harmful “empathy tax.”
This term has been used by Sarah Ross in leadership coaching, and when applied to the health care system, the “empathy tax” disparately affects those physicians with higher across gender empathy. However, additional harmful, burdensome expectations are placed on women physicians for exhibiting high empathy, such as spending more time with patients than their male colleagues.
This empathy tax means that, in general, women are performing significantly more labour that is not acknowledged or billed. This labour may show itself as providing emotional support and counseling to patients, giving thorough social welfare assessments requiring time-consuming follow-up, filling systemic gaps from shrinking resources performing the duty to care, receiving more complex, time-consuming cases while being unable to bill for the additional time due to lacking OHIP billing codes, organizing departmental social events, informal or formal mentoring, and taking on extra responsibilities. The list from literature and my clinical sessions goes on —all of which sustain the public healthcare system in Canada but comes at an enormous personal cost.
This diffuse web of mostly invisible additional relational, empathic, cognitive, administrative, clinical labour all occurs before the woman goes home, after a long day or long night on-call. Once home, then begin the socially prescribed expectations to provide a lion’s share of caring, cognitive, administrative household labour to keep a home running smoothly, children’s lives supported, care for aging parents, supporting and engaging with friends, being asked for medical knowledge and input but ill neighbours, friends of friends, distant cousins…. the invisible labour for women goes on and on without end in sight for many. With part of the empathy tax being that the woman physician is expected to provide a service and duty to care more, ad hoc as both physician and woman, both roles double the tax on her empathy networks neurologically and cognitively. As a woman, there are well-documented, more punitive reactions from both men and women if she sets firm boundaries, steps back, falls ill, and/or takes a break.
Empathy Double-Binds—Women Physicians and the Sword of Damocles
In sessions and public presentations with women physicians, I have found this aspect of the empathy tax to be the one that sparks the most discussion and “aha” moments. Their lived experiences, typically tacit, invisible, and ever present, get a name and are rendered visible. Suddenly, women physicians have a means to disidentify the problem they have been believing was somehow (a) within their control to change and (b) still due to some failing of effort on their own part to “get it right.” I liken the empathy double binds in women’s lives and medical culture to the “sword of Damocles” experience. Here is the story retold from Wikipedia’s version:
Damocles was showering King Dionysius with flattery, marveling at how lucky the king was to wield such unmatched power and authority while being surrounded by luxury. To teach him a lesson, Dionysius offered to trade places for a day, giving Damocles a chance to experience this so-called fortune firsthand. Overjoyed, Damocles agreed. He settled into the king’s throne, surrounded by opulent decor, intoxicating fragrances, and the devoted service of attendants.
However, Dionysius, who had amassed plenty of enemies during his reign, had arranged for a sword to hang directly above the throne, suspended by just a single strand of horsehair. The precarious blade was meant to symbolize the constant peril that came with power. For all the wealth and privilege at his command, a king’s life was shadowed by anxiety—always on edge, wary of treachery, political missteps, or threats from rivals.
As the reality of this burden sank in, Damocles begged to step down, realizing that no amount of riches or splendor could ease the tension of what loomed overhead.
The Queen Bee Problem - By the time a woman has completed residency and the Royal College Exams for entry to full practice as a physician, she has learned to survive in an exclusively competitive environment, akin to survival in the shark tank. She has thus inevitably “made enemies” as Dionysius had. She has experienced betrayal by trusted friends in her resident cohort because they are competing for jobs post-graduation. Some have learned to master the systems of power and have been predisposed to have skills that can wield that power over and up against others to get ahead. Typically, these come from the skills learned early to survive trauma and dysfunctional family systems. Survival required the navigation of power and self-preservation. The competitive environment requires the maintenance of one’s guard to disbelieve that anyone is truly a friend—the goods for survival as so few and so unequally distributed, it is forever the dynamics of prison where crumbs of rewards are scrapped over, and the most skilful bully wins. Aggression between girls and women can perpetuate far under the radar and are difficult to ‘out’.
Odd Girl Out by Rachel Simmons was a seminal book based on her qualitative research that shows the corrosively insidious and overt ways bullying takes shape between girls which often develop into masterfully polished survival skills in adult women for the perpetuation of career and income. A frequently stated phrase in many women’s lives, including physicians, is that “women are the worst” in how we treat each other. Deprivation of essential needs being met can create tinder for betrayals of the most painful kind, all in the service of survival. Likely none of us are without guilt, but systems that do not serve the core values of human well-being in its employees tend to promote those who have become highly skilled in those survival methods that mute empathy, compassion, mutuality, and trust. Instead, these systems encourage employees to play master chess with colleagues’ careers in the “best interest” of the organizations. Leaders can perpetuate and amplify organizational betrayal, a key component of moral injury. Moral injury renders a person at great risk of complicated PTSD/mental health collapse. It is a tough trauma to heal from, particularly when it is inflicted by a woman that was perceived as ally, one who would understand the complexities faced by a woman physician. When the affected woman physician speaks up about this trauma, she is labelled as petty, emotional, and even paranoid, further rendering her invisible.
The Scapegoat problem - Others have struggled to navigate the power dynamics, likely having lived through trauma themselves and formed a different coping pathway that involved not participating in gaining power and take on the role of scapegoat, the one projected upon as “the problem.” These individuals are the ones who seem to repeatedly suffer and fall behind in the culture of medicine as it is institutionalized into power structures within care delivery systems and its academic institutional arms.
The Hunker Down & Be Invisible problem – Another coping style in a system of oppressive power and harmful dynamics is to become the invisible one who suffers very silently, becomes the workhorse, ekes out the career, carves out her trajectory and watches what happens to those who do speak up and out, explode or push against the system. She then learns the lesson that to be invisible is the best and only option. The accompanying price is that she becomes invisible to herself, loses touch with her needs, her authentic voice, her passion, and her vision. A silent implosion can happen over time.
This gap of capacity for survival and gaining a toehold in the career ladder (meaning having to become a shark to swim with the sharks) tends to widen between the Queen Bees, the Hunker Down & Be Invisibles, and Scapegoats upon graduation from residency. This is due to the lack of structures of supervision, mentorship, learning groups, or in Canada, the lack of the resident’s union for protection of human rights, which was not privileged to the millennials, Gen X, or Boomer physicians in their training. These structures, flawed as they are ensuring that the majority of residents successfully graduate, demonstrate that the “system works” for training future participants in the culture of medicine, regardless of the resident’s mental health and well-being at the point of graduation. They’ve “arrived” at the threshold, which admits them to the bastions of the medical culture—a privileged place in society, so they’ve been led to believe.
There are many promises made to medical students along the way of future “goods” they will yield—money, status, fancy holidays, keynote speaking, and a global positive regard of their work, all under the guise of an altruistic ideal for serving society with a Most Important Good—public health, human well-being, human dignity, and care. Yet all are delivered within a system that masks its own central, but hidden interest, which is a large, global economy of profiteering disguised as public health.
This is a simplistic generalized statement, but the core values are clear and simple. When they are hidden, and a whole entire power system exists to gaslight its population to look away from the self-interests at its core, then it gets complicated. Many wonder, for a long time, why they can’t seem to “make it” as they see other colleagues doing or their older colleagues, who they see retiring in droves. The struggle is deeply internalized as a personal issue, which the system is more than happy for its human components to believe. The system is no one, no group, no “secret global conspiracy,” but just a series of building blocks that created a world and global model of health care delivery that no-one can see how to change now.
Slyvia Cruss (2006) writes an in-depth analysis of the societal contract between medicine and the competency of “professionalism” expected of physicians. In Canada’s Royal and Family Practice Colleges, this competency is now codified into medical training and professional development throughout a physician’s career. Cruss examines this expected competency and its enactment between physicians and citizens seeking medical care, which requires and enacts relationships of “trust and reasonable demands.” She summarizes the article’s key points stating:
Society's expectations of medicine are: the services of the healer, assured competence, altruistic service, morality and integrity, accountability, transparency, objective advice, and promotion of the public good.
Medicine's expectations of society are: trust, autonomy, self-regulation, a health care system that is value-driven and adequately funded, participation in public policy, shared responsibility for health, a monopoly, and both non-financial and financial rewards.
The recognition of these expectations is important as they serve as the basis of a series of obligations which are necessary for the maintenance of medicine as a profession.
Mutual trust and reasonable demands are required of both parties to the contract.
Now, this concept of a deeply harmful and multi-faceted higher empathy tax is foregrounded from its implicit presence in gender discrimination literature highlighting the price (including financial) that women physicians pay in every area of their lives. We can place that insight into this broader context of how this society has failed to uphold its contractual obligation to share responsibility for citizen’s health and is failing physicians, most especially, women physicians to uphold its contract for trust and reasonable demands. The demands have become utterly unreasonable and impossible to fulfill across a career.
Time and again, I hear from the physicians, particularly those in family practice, of rising levels of verbal abuse and legal complaints tying up time and adding enormous mental and emotional stress as the resolution process stretches out over months, even years. There is an increase of patients reporting dissatisfaction with their doctors to the college.
We also see in the news the dangerously long waits for treatment in emergency rooms, emergency room closures in smaller communities, and the lack of family doctors for millions in Ontario. Health care delivery is increasingly problematic in many of the countries that claim to hold the well-being of their citizens as a central value.
We are seeing serious breakdown in many societies’ attempts to deliver health care. They are also failing to uphold a political-social-cultural obligation for “mutual trust and reasonable demands” with and upon their countries’ physicians. The literature on women physicians’ experiences of public and interprofessional expectations, attitudes, and retaliatory blowback when they fail to meet gender imbalanced expectations shows a clear picture that women physicians are enduring much higher levels of this fallout in all areas of their lives. Once again, women physicians are paying a higher price for society’s failure to provide reasonable and foundational resource allocation for their medical practices.
For women physicians, the tensions are endless, invisible, and uncompromising, similar to the sword over Damocles’ head. She does indeed have many “enemies,” as Damocles realized when spending a day on the throne of the king he envied. These enemies—gender bias, egregious gender discrimination, pay inequity, promotion/research grant/conference invitation inequities (all required to advance in academic medical education and research tenureship), patient, collegial, and supervisory expectations for more responsiveness in emails, expectation for more time spent showing empathic care and counselling with patients, more wrap-around social welfare assessments and referrals to needed social welfare supports, etc.—do not hold the woman physician’s best interests in view. It is quite the opposite, in fact; all the way up the system’s food chain and all the way down to the most subordinate individual in the hierarchy of power and pay cheques, the woman physician is impacted across her career.
Empathy double binds are embedded in all of these tensions, sitting like the sword of Damocles over each woman’s head. One foot wrong, one word said in a tone that isn’t just right, one mistake of personality, practice efficiency, and/or practice competency, will incur a potentially permanent consequence in that relationship. This creates a barrier to her ability to get her job done and to get the investment relationally from others, both essential for successful function as a physician and as a person.
Temken et al (2024) in their article on Gender and the Physician Workforce: Challenges for Women Physicians outline and name these aspects from their own research.
Illustrations: Designed in Canva by Martha Elliott
from a handout in Self-Compassion for Women Physician Retreats with Helen J Butlin, RP, PhD
What are The “Empathy Double Binds”?
Gender Roles and Norms in Medicine
Women physicians face significant challenges tied to gender roles and norms, which demand additional unpaid labour, time, and emotional energy to navigate effectively.
Status-Leveling and Unpaid Labour: Women often feel pressured to make themselves overly available, undertake tasks traditionally assigned to other healthcare team members, and exhibit "performative niceness" to secure cooperation from colleagues, particularly nurses (Cardador et al., 2022)
Gendered Patient Expectations: Patients frequently expect women physicians to:
Spend more time during appointments.
Provide both medical care and social connection.
Exhibit higher levels of empathy compared to male counterparts (Linzer & Harwood, 2018; Mast & Kadji, 2018)
Additionally, women physicians often treat a higher percentage of women patients, who typically require and expect longer, more communicative visits. Despite these demands, additional time to meet these expectations is rarely accounted for, contributing to increased burnout rates among women physicians (Linzer & Harwood, 2018).
Electronic Communication Burden: Data from electronic health records show that women physicians receive over 20% more messages from staff, colleagues, and patients than men, further increasing their workload (Rittenberg et al., 2022).
The "Double Bind" and Bias in Perceptions of Competence
Competence vs. Likability: Women in medicine face the "double bind" dilemma, where:
Those who demonstrate assertiveness and decisiveness are seen as competent but not likable.
Those who display stereotypically feminine traits are perceived as likable but less competent (Catalyst, 2007).
This creates a narrow behavioural lane for women aspiring to leadership roles. Deviating from this lane—either by being too assertive or too nurturing—often results in social penalties that can impede career advancement.
Bias and Perception: Gender biases are pervasive across all demographics, including among healthcare professionals themselves. Surgeons who are women, for example, are often seen as "warm" but less competent, forcing them to invest additional time and effort to prove their expertise (Ashton-James et al., 2019; Salles et al., 2019).
Pay Disparities and Structural Inequities
Illustrations: Designed in Canva by Martha Elliott
from a handout in Self-Compassion for Women Physician Retreats with Helen J Butlin, RP, PhD
Pay Disparities in Specialties: When the proportion of women in a medical specialty increases, the average pay for all practitioners in that field declines. For every 10 percentage point increase in women within a specialty, median annual salaries drop by over $8,000, regardless of the physician’s gender (Bravender et al., 2021).
Reimbursement Inequities: Procedures performed on female patients are reimbursed at rates that are, on average, 28% lower than equivalent procedures for male patients (Benoit et al., 2017).
Professional Representation and Research Disparities
Conference Representation: Women physicians remain underrepresented as invited speakers at medical conferences, while men are disproportionately overrepresented (Gerull et al., 2020).
Publication Inequities: Clinical health-related research focused on women, which is more often conducted by women scientists, is accepted for publication at lower rates than comparable research focused on men. This disparity persists even when the scientific rigor and impact of the research are deemed equivalent (Murray et al., 2021).
Women physicians navigate this landscape shaped by gendered expectations, biases, and systemic inequities every single day. Every single interaction with every single individual in health care delivery systems is laced with these dynamics for every woman physician. They are certainly embedded for all women in all roles, but the unique complexity for a woman physician is that she is carrying the ultimate responsibility for the life and health of her patients. This must take precedence over any other concern or focus for her in order to fulfill her social and professional responsibility to the patient.
Research has consistently shown over many years that this strain, pervasive across specialties, takes a heavier toll on women and underscores a persistent culture of patriarchy and misogyny, adding to the challenge of balancing professional demands with personal well-being.
The Post-pandemic “Second Shift” - One further, major contributing factor to this extra toll on women physicians is the product of a social norm endemic to cultures of patriarchy and what Hochschild termed, “The Second Shift” (1989). The healthcare system's reliance on this unpaid emotional labour is contributing to extensive burnout, women leaving the profession of medicine in higher numbers, worsening mental health, and so on.
In a review published by the Canadian Association of Medicine with the Federation of Medical Women of Canada, many key points are highlighted on the state of inequities women in medicine are facing. They cite Ly D.P., et al (2017) in a study on Hours worked among US dual physician couples with children, 2000 to 2015 note that women during the years this study covered were working 11 hours less than their male partners to accommodate the needs in the home. This was prior to the pandemic when this disparity widened.
During the pandemic, women globally experienced increased intimate partner violence, a disproportionate burden falling to them versus male partners for the additional labour of juggling children’s online education while simultaneously working themselves, and an ongoing slide of household labour onto their plates. This tends to happen even in the most egalitarian households, observable in the differing narratives during the years of my oncology counselling practice. Division of labour in the home is a generalized challenge for many households and is certainly not limited to the differentiation of gender, but it is often a notable topic in therapy practices where a heterosexual couple are co-habitating.
Dismantling the Internalized Oppressions: “It’s NOT You!”
The illustration below shows the themes frequently present in women physicians’ self-talk, including ways in which internalized oppression is experienced. Historical, socio-political, and cultural (including medical culture) influences affect the tension surrounding women physicians and their lived experiences. This can be applied to the many societies that use the Euro-American, colonial model of medical training and delivery. In the picture, you can see how the many influences on the woman create an impossible set of double-binds, tensions between personal, social, global interests and how these spheres, far beyond her individual influence, are internalized into self-critical thoughts believing the deficit is located within herself. She may also feel that there is something wrong with her, and it is on her to solve the problems she faces in balancing work, home, social/mental well-being, parenting, caring for elders, etc. Contextually, there is no option to have any balance, and the deficit is not personal but societal; this is missed in the thoughts swirling in her head about herself and her life. This is further compounded by the precious little time that she has to notice her internal narrative and thoughts about herself and her life.
While this issue illustrated below is specific in the Canadian context, it is also relevant to many other countries where medical institutions and practices have been shaped by Western colonial-patriarchal ideologies, affecting the mental health, self-identity, and well-being of individual women physicians.
Illustration: Content designed by Helen J Butlin, PhD
Artist: Martha Elliot, MSW, RSW
Recognizing Your Own Version of the “Internal Oppressor”
For many women physicians striving to do their best and better in all areas of their lives, there is an internal, pervasive, self-critical inner voice shaping a core self-identity with toxic, shaming narratives designed to perfect, demean, undermine, and belittle. The external pressures formed by the devaluing of women in a society, no matter what gains are made to their public roles and careers, become internalized over generations, leading women to mistake the critical voice in their mind as their own. This voice reflects a patriarchal and colonial perspective, distorting one's valuable worth as a human being. It is toxic and needs to be addressed and neutralized.
Many of the brilliant, incredibly resilient women I have worked with both as colleagues in my years in health care as well as in their healing through therapy and the self-compassion retreats have battled this inner critic and all the while exceptionally juggling multiple roles—physician, partner, daughter, sister, friend, parent. Yet, this internalized critic incessantly chastises for not doing it all perfectly, and if one area of life feels ok, other areas of herself and her life are judged, often harshly, as not good enough.
It is no wonder that mental, emotional, and physical strain takes a toll in a system that starves women physicians of the resources you need to care for others and yourself.
Rebuilding your sense of self-worth and validating you as person with valuable qualities, regardless of outcomes, protects you from the systemic and interpersonal distortions in medical culture. Over time, these distortions can damage your sense of identity, mental health, personal well-being, and career advancement capacities.
As Krishnamurti is attributed to saying, "It is no measure of health to be well adjusted to a profoundly sick society." What I’ve witnessed in my clinical practice and women physician retreats is that there’s little bandwidth to keep adapting.
Yet, you continue to hold your patients’ humanity at the forefront, but who is holding yours?
Know you’re not alone. Join with others in this project for change starting internally by rejecting the scripts of “defective,” “not good enough,” “what’s wrong with me?”, and “I can’t keep this up for my whole career.” Integrating the principles and practices of tender and fierce self-compassion, differentiated forms of self-compassion harnessed and operationalized by Dr. Kristen Neff (2021) in my life and work with women is framed as an act of both resistance and empowerment.
Good News! Harnessing Neuroplasticity to Form Your “Wisdom-Compass”
The organically formed “wisdom-compass” methodology that my life and therapy practice is formed around has been distilled over thirty years from my academic training that began in 1996 in feminist-based scholarship, my subsequent clinical practice, and culminating in my doctoral research that was anchored in feminist bioethics (Butlin, 2018). My study drew on the perspectives of women on lived experiences of embodied, intuitive, reflective life “wisdom” while living with ovarian cancer. This lifelong scholarship and clinical development in therapy has been simultaneously deeply grounded in my own life and ongoing personal integration and has distilled to a wisdom-compass formation methodology that can stay with you, uniquely formed in your own life, for navigating the rest of your life.
As bell hooks, a world-renowned feminist scholar (who never capitalized her name) once wrote, “theory saved my life.” In the book this quote is from, hooks reflects on how theoretical frameworks and intellectual pursuits, particularly those related to feminist theory, provided her with both personal and intellectual liberation. The quote encapsulates her perspective on the transformative power of theory in personal and collective growth, especially for marginalized groups. When I was a mother of very young children in my mid-thirties, unbuckling from untreated postpartum depression and birth trauma, riddled with personal “motherguilt,” with shaming self-narratives from not being able to cope with managing a baby and a voraciously spirited toddler, hooks’ quote, culled in my Master’s thesis, did quite literally save my life.
My feminist sister-scholars gave me a lens to know this internalized shame and sense of profound failure as a human being and mother was not actually true. I could question the incessant inner voice criticizing me through the day and night, and it was this internalized motherguilt that drove me into therapy again.
With the infinite patience of my therapist, I was able to extract the relentless, internalized messages from a society failing to support women (and all parents) in the early years of child-rearing with anything close the village of multi-faceted support that is required. I deepened the internal work of dismantling these narratives from my self-identity.
From this process in my own lived experience and many of my clients, it is a consistently effective process that slowly but surely forms a deep, unshakeable internal navigational wisdom. This wisdom can and does enable us to continue to work on the small and herculean changes needed to change toxic societies formed in the ideals and politics of patriarchal misogyny. A task across the globe that is becoming ever more pressing today.
Forming your own personalized embodied, intuitive, reflective wisdom-compass integrates evidence-based practices, skills, and therapy modalities that, over time, form a more instinctive capacity for healing and recovery from past trauma, professional vicarious trauma, ethical distress, moral injury, and cumulatively harmful contexts in personal life and workplaces. This can provide you an internal “zone of resistance” (Biradi, 2009) and aid you to find allies and connections with others seeking ways to change systemic barriers and biases in creative, purposeful, and persistent ways.
Forming your internal wisdom-compass grounded in critical reflexivity and self-compassion aids a ripple effect for change, from internal to external spheres.
This wisdom-compass methodology in my therapy practice is developed from four pillars of skills and evidence-based therapies, combining neuroscience and trauma-informed psychology in an integrative approach.
The Four Skills for Harnessing a Physiology of Change
These interweaving skills, developed over time, provide you with (re)empowerment, persistent capacity for resistance to oppression (internal and external), and activation of your human psyche’s wisdom-making capacity to find the small steps that can create the powerful tipping points for radical change, personally and collectively.
Critical Reflexivity - teaches each person to look out first and “name the things”—the invisible, impactful oppressions, discourses, biases, and barriers circulating around and through your life, at home, at work, and in public spaces. Critical reflexivity helps you recognize what harms are shaped into your lived experience through their silent but relentlessly forceful presence in policy, cultural norms, institutional culture, and so on.
Polyvagal Therapy - offers a science and methodology for listening to and shaping the nervous system to grow a strong and robust parasympathetic-regulating neurology that enables us to harness anger, recognize distress and numbing states, and heal them into an accessing of a uniquely individual experience of an inner reflective, intuitive, and integrative “wisdom-compass.”
Self-Compassion Therapy - especially tailored for busy women in a biased society, this therapy draws on decades of research by clinical experts and researchers: Dr. Paul Gilbert, Dr. Kristen Neff, and Dr. Christopher Germer. Dr. Neff's concept of “Fierce Self-Compassion” (2021) specifically addresses women's unique challenges. I found Dr. Neff’s research in 2009 and started working self-compassion into my oncology support groups. By the time I trained formally in the Self-Compassion Therapy Intensive in 2021, there were over 3,500 studies demonstrating its benefits in areas like mental health, addiction recovery, and athletic performance. It works. But you have to figure how it can work for you; sessions or retreats focus on the practical keys that work best for you.
You may want to take this validated Self-Compassion Test developed by Dr. Kristen Neff here to see how you’re doing with self-compassion: https://self-compassion.org/self-compassion-test/
Healing past trauma - Past trauma is stored in your nervous system and memory networks. It renders you vulnerable to being re-triggered in the present, and old survival modes can be an autonomic method of coping that your nervous system habitually uses to enable your survival. But survival mode is not meant to be a way of life and eventually causes deteriorating mental health (the brain’s loss of ability to manage stress). Often, when past traumas are combined with frontline exposure to human suffering, traumatic events where lives must be saved at all costs, including your own, along with the systemic under resourcing of your career, PTSD symptoms can develop. Brains can only recover so many times from overwhelming and prolonged chronic stress and trauma events. Healing past trauma allows present traumas and stress to be just that —present—and builds skills and resiliency in your neural networks to be able to recover in real time. Then you can work towards recovery and re-anchoring into well-being more effectively and quickly.
If you’d like more information about skill-based Self-Compassion for Women Physicians learning retreats specifically integrating critical reflexivity, self-compassion, polyvagal attunement to your nervous system, shared humanity with other women physicians, (8-15 participants), please feel free to reach out.