Social Science and Medicine 52 (2001) 331–343

Medical women } towards full integration? An analysis of the

specialty choices made by two cohorts of Norwegian doctors
Elisabeth Gjerberg*
Work Research Institute, PBX 8171 Dep, Stensberggt. 29, N-0034 Oslo, Norway

Abstract

In Norway, as in most Western countries, doctors’ choice of specialty has been strongly gendered. Female physicians
have tended both to specialise to a lesser degree and to enter other specialties than male colleagues. In spite of the
increase of women in medicine, previous studies have not managed to show any changes in this pattern. Comparing
data from two cohorts of Norwegian doctors, authorised in 1970–73 and 1980–83 respectively, this article demonstrates
that changes are in fact taking place. The changes are, however, not unequivocal. Firstly, women in these cohorts
specialise to a very high degree and just as much as their male colleagues. Secondly, women doctors of the 1980s cohort
spread their choice of specialisation over more fields than their predecessors did. They have, for example, started to
enter surgery, although still not as often as men. Thirdly, proportionally more doctors of the 1980s cohort than the
1970s cohort have chosen general practice as their main specialty, and this applies to both women and men. Fourthly,
there are tendencies towards an increasing concentration of women in some disciplines such as obstetrics and
gynaecology, as well as paediatrics. These changes in doctors’ pattern of specialisation are discussed as consequences of
socially shaped individual preferences, structural aspects of the Norwegian health system and the existence of gendered
closure mechanisms within specific medical fields. Although the medical profession still appears as a gender
differentiated community, the article gives a more dynamic and in some respects a more optimistic picture than earlier
studies. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Medical women; Choice of specialty; Gender differences; Norway

Introduction to 4319 in 1998. If today’s trend continues, with about

Like other European countries, Norway has seen a
marked increase of women in medicine, especially in the
last couple of decades. From the period between the
World Wars up to the last half of the 1970s, the
percentage of women in Norwegian medicine remained
fairly stable at about 12–14% (Gjerberg-Buxrud, 1994),
but since the end of the 1970s there has been a marked
increase, and in 1999, 30% of all professionally active
doctors are women. However, this almost doubling of
the proportion of women physicians over the last three
decades conceals an even more remarkable growth in the
absolute number of female physicians, from 731 in 1970
*Tel.: +47-22-46-16-70; fax: +47-22-56-89-18.
E-mail address: gjel@afi-wri.no, (E. Gjerberg).
50% of the newly qualified doctors being women, and
nearly all those retiring being men, in the year 2015,
about 45% of Norway’s professionally active doctors
will be women. A similar change in the gender
composition is expected in the other Nordic countries
(The Nordic Medical Association 1998)1, in Great
Britain (Allen, 1988) and in the United States (Kletke,
Marder & Silverberger, 1990).
1
Compared with other Nordic countries, Norway has a
relatively low percentage of qualified women doctors: In 1999,
49% of Finland’s professionally active doctors are women,
while the corresponding figures are 38% in Sweden, 35% in
Denmark, and only 20% in Iceland (The Nordic Medical
Associations 1999)

0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 1 3 8 - 6
332 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
The most pronounced increase in the number of
women in Norwegian medicine occurred from the last
half of the 1970s and should be seen in the light of other
changes that were taking place regarding women’s
position in society. During the 1950s and 1960s,
increasing numbers of young women acquired higher
levels of education. But the great educational
revolution for Norwegian girls only really got
going in the 1970s (Skrede, 1994). From the cohort
born in 1950 and onwards, there was a marked increase
in the number of women who proceeded to college and
university education. In the 1960s and 1970s, new
attitudes both to the role of women in society and to
gender equality became more apparent in public debates
and later also in practical policies (e.g. improved
maternity leave, more kindergartens, etc.). Education
has an important effect on changing attitudes to status
equality and vice versa. During the 1970s and 1980s, an
increasing number of women applied for higher educa-
tion in fields that had previously been the domain of
men, for example law, civil engineering, and medicine.
This is the case in all Western European countries,
where women are increasingly qualifying for and
practising professional occupations. However, the in-
crease of women in medicine from the 1970s was not
only an effect of changing attitudes, but also a
consequence of an expanding health care system. In
1970 there were 5196 active doctors in Norway, in 1981
the number was 8311. Thus, the expansion of the
physician labour market made it easier for women to
enter the medical profession.
In spite of the influx of women in medicine, many
previous studies have argued that there has not been a
full integration of women in the medical profession, with
regard either to vertical or horizontal divisions. Thus,
women have been strongly underrepresented both in the
higher positions in the medical hierarchy and in certain
medical specialties. This has been the case both in
Scandinavia (Arnesen, Myraker, Steinsholt, Thesen &
Ørbeck, 1974; Flottorp, 1993; Hovig, 1993; Korremann,
1994; Kværner, Botten & Asland, 1999) and in other
Western countries (Riska & Wegar, 1989, 1993; Elston,
1980, 1993; Lorber, 1984, 1993, Kletke et al., 1990). I
demonstrate in this article that changes are taking place
as far as the horizontal segregation is concerned. Female
physicians educated at the beginning of the 1980s are
better integrated in the various medical specialties than
female colleagues educated a decade earlier. In order to
study the specific changes in the horizontal integration
of female physicians, I have chosen to study both to
what extent doctors become specialists and which
specialties they choose. This is because specialist training
is increasingly necessary in order to become established
in a professional field and because a choice of type of
medical work in Norway depends largely on the choice
of specialty.
To study recent changes in horizontal integration, one
has to look at doctors who are young but have
nevertheless had sufficient time to become a specialist.
Specialisation is time consuming: it takes from five to six
years to accomplish, depending on the field chosen.2 It
takes approximately nine years after authorisation as
doctors to finish training for a first specialty, and 85% of
those who are specialists have accomplished their
specialist training within 5–15 years after authorisation
(The Norwegian Medical Association, 1998; Gjerberg &
Aasland, 1999). Thus, it is not until now, approaching
the end of the 1990s, that changes in the pattern of
specialisation of the ‘‘new’’ female doctors could be
revealed. Also, it is important to bear in mind that
changes in specialisation patterns of younger cohorts of
female physicians will only have a small effect on the
present overall picture of the whole population of
doctors. Consequently, in order to investigate possible
changes in the specialisation pattern of the younger
cohorts of physicians, I chose to compare two cohorts of
doctors, i.e. doctors who were authorised in the period
1980–83, using doctors authorised ten years earlier as a
baseline. Do women doctors of the 1980s cohort
specialise to a higher degree and choose specialties more
like male than female colleagues educated about ten
years earlier? How can possible changes be interpreted?
After briefly presenting factors that may affect the
horizontal segregation of women in medicine, the article
gives a short summary of earlier studies on gender
differences in doctors’ choice of specialties. I then
demonstrate the specialty distribution of recent cohorts
of Norwegian physicians, focusing on tendencies to
change. Finally, the last section of the paper discusses
the findings as consequences of, respectively, (1)
individual preferences reflecting for example the new
role of women in society, (2) the opportunity structure
within medicine, and (3) closure mechanisms in medical
specialties.
2
The regulations for becoming a specialist include a
requirement of between five and six years employment in
addition to pre-determined course attendance and supervision.
A four-five year period of employment in the main specialty is
required, as well as six to twelve months subsidiary education.
For example, in order to become a specialist in general
medicine, five years employment is required in a department
of general medicine that covers the main fields of this specialty.
In addition, he/she has to be employed for one year in
subsidiary employment in a relevant clinical field. If he or she
wants to go on to a branch specialty, e.g. become a cardiac
specialist, three years are required at a recognised institution for
training in heart diseases, two of these in a regional or
university hospital. Up to one year of training can be included
in the specialist training in general medicine. In order to become
a specialist in heart diseases, at least eight years of post-
graduate education are thus required (Yearbook of The
Norwegian Medical Association 1997).
 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
Factors that may influence the horizontal integration of
women in medicine
Two types of explanations have been offered to help
understand occupational sex segregation: individual and
institutional/contextual (Crompton & Sanderson, 1990;
Riska & Wegar, 1993). Individual-oriented explanations
describe gender differences in career choices in terms of
individual, but gender-related, preferences or personal-
ity traits. Explanations at an institutional level point at
structural factors in contemporary health care as well as
structural operating barriers or closure mechanisms
within specific fields.
Individual career preferences
Two types of individual-oriented explanations have
been presented: (1) the human-capital theory, and (2) the
socialisation theory. According to the human-capital
theory, individuals make long-term investments in
education and career choice, based on rational decisions
on probable future ‘‘earnings’’ (Polachek, 1976). For
instance, women’s choice of career may reflect their
desire to try to balance their domestic and occupational
roles. By extension, the under-representation of female
physicians in most hospital specialties may reflect
women’s uncertainty about whether their domestic and
family circumstances are compatible with a career in
hospital medicine (Martin, Arnold & Parker, 1988;
Uhlenberg & Cooney, 1990; Gjerberg & Hofoss, 1998).
The other type of individual-oriented approach explains
the gender differences in occupational orientations as a
function of socialisation. That is to say that gender
specific preferences and personality traits develop
through socialisation, for example that women are
assumed to possess natural skills for ‘‘emotional work’’
(James, 1989; Heins, Hendricks, Martindale, Smock,
Stein & Jacobs, 1979). Thus, the high proportion of
female physicians in psychiatry, gynaecology, and
paediatrics may reflect their gender-related interests
and skills.
Structural changes in health care } the opportunity
structure
Norwegian doctors who started their professional
career early in the 1970s and 1980s were facing an
expanding health service. The Hospital Act of 1970
meant extensive expansion of hospitals, and thus also a
great increase in job opportunities. From 1970 to 1976
the number of doctors working in the hospital health
services increased by about 38%, compared to 20% in
non-hospital services (Central Bureau of Statistics,
1978). Doctors’ salaries and working conditions im-
proved far more in hospitals than in the district health
services. Parallel to this development, increasing concern
333
was being expressed about the low recruitment of
doctors to general practice and public health jobs,
concluding that the primary health services needed
strengthening (Parliamentary Report No. 85, 1970–
1971; Parliamentary Report No. 45, 1972–1973; Norwe-
gian Official Report, 1979, p. 28). The National
Government created a number of jobs as District
Medical Officers, and fixed salary jobs for doctors were
established by a large number of municipalities. The
level of pay in these jobs made it more profitable to be a
general practitioner than it had been before. Moreover,
as part of the implementation of the Municipal Health
Services Act of 1982, a lot of positions were established
in the primary health services. During the period 1968–
1975, university institutes for general practice medicine
were established, in 1983 the Norwegian College of
General Practitioners was founded, and in 1984–85
public health and general practice were approved as
separate specialties. The priorities of health policies were
thus changing in this period, affecting both the
opportunity structure, the ideology and, as we shall
see, the career choices of young doctors.
Closure mechanisms within medicine
In the 19th century, women were subject to formal
exclusionary practices in medicine, i.e. they were
collectively excluded from medicine on account of their
gender (Drachman, 1986; Schiötz & Nordhagen, 1992;
Witz, 1992). In the twentieth century, the existence of
unofficial exclusionary practices have been discussed. It
has been argued that the under-representation of women
both in top positions and in different specialties are
consequences of male exclusionary practices, i.e. gender
biased barriers which tend to restrict the entry of women
(Lorber, 1984; Riska & Wegar, 1993; Gjerberg &
Hofoss, 1998; Kværner et al., 1999; Crompton, Le
Feuvre & Birkelund, 1999). To understand the dispro-
portionate representation of women in medicine as
results of exclusionary practices is a reflection of the last
decades’ revision of theories on profession and profes-
sionalism. Rather than understanding professions as
altruistic occupations, professions were increasingly
described as institutional means of controlling occupa-
tional activities (Johnson, 1972; Freidson, 1977; Abbott,
1988). Crompton (1987), Witz (1992) and Davies (1996)
argue that the professions are not only characterised by
closure mechanisms, but that these strategies are
gendered, i.e. exclusionary practices depend on the
gender of the participants involved. For example,
attention has been drawn to exclusionary practices,
giving preference to male doctors, as an explanation of
the sparse representation of women in surgical special-
ties (Nore, 1993; Riska & Wegar, 1993; Crompton, Le
Feuvre & Birkelund 1999).
334 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
Both changing preferences, expansion/contraction
within fields and altering closure mechanisms may thus
affect the horizontal division in medicine. These factors
are not mutually exclusive, each may be present to some
degree at the same time.
Women’s position in medicine: a brief historical
background
For a long time female physicians have tended both to
specialise to a lesser degree and to enter other specialties
than male physicians. However, early this century,
Norwegian female physicians were not underrepresented
among the specialists: in 1929, 16% of the women were
specialists, compared to 14% of the men (Larsen, 1986).
However, since then and until recently, the degree of
specialisation has increased more among male than
among female doctors. In 1972, 28% of the women and
40% of the men were specialists (Arnesen et al., 1974),
and in 1992, Flottorp (1993) found that 38% of the
female doctors and 69% of the male doctors were
specialists. Studies based on cross-section data from
other Nordic and Western countries have also shown
that fewer female than male doctors have chosen to
become specialists (Lorber, 1984; Riska & Wegar, 1993).
However, our study of Norwegian doctors in the
beginning of the 1990s showed that the degree of
specialisation of male and female doctors is converging
among younger doctors (Gjerberg & Hofoss, 1995).
Although some attention has been paid to the degree
of specialisation, the main focus of attention has been on
the differences that have existed between women and
men in their choice of professional field. When women
entered the medical profession in Norway about a
hundred years ago, a gender-based division of labour
soon became established. Women concentrated on a
small number of professional fields (7 of 19 possible
specialties), whereas men were spread over the whole
spectrum of specialties (Larsen, 1986). This pattern has
been confirmed to a large extent in more recent cross-
section studies: to a greater extent than men, women
have chosen professional fields involving women and
children. They have also been found in disciplines that
represent a high degree of patient contact such as
psychiatry, child and adolescent psychiatry, and to some
extent general practice. On the other hand, they are also
well represented in disciplines where there is no contact
with patients, such as pathology, but where the working
hours are favourable (Arnesen et al., 1974; Steinsholt,
Ryah & Thesen, 1990; Flottorp, 1993). Although several
of these fields represent better possibilities for attractive
working hours than most hospital specialties, the
connection is not consistent. For example, obstetrics
and gynaecology as well as paediatrics, which in Norway
are mainly hospital-based specialties, involve long
periods on irregular hours. While women have been
represented in their expected proportion (or even over-
represented) in specialties like paediatrics, general
practice and psychiatry, in most Western countries
women doctors have been strongly underrepresented in
general surgery and surgical subspecialties. The distribu-
tion of women in the various fields may indicate that
some give priority to work that involves favourable
working hours, while others put more weight on certain
professional challenges or work with special groups of
patients. This pattern of gendered choice of specialties is
seen with some variations throughout the Nordic
countries (Riska & Wegar, 1989, 1993; Korreman,
1994), in Great Britain (Elston, 1980; Allen, 1988), and
in USA (Lorber, 1984; Kletke et al., 1990).
Gender-based work differentiation has also been
demonstrated within medical fields. For example,
women in general practice are more likely than men to
remain in a practice with a strong emphasis on
gynaecology and reproductive functions (Brooks,
1998). Other signs of ‘‘ghetto’’ formation in general
practice have been pointed out by Riska and Wegar
(1993), who show that in the Finnish primary health
services, more often than their male colleagues, women
doctors are found with a fixed salary job at public health
centres. To sum up: it has been shown repeatedly and in
different countries that doctors’ choice of specialty has
followed a fairly gendered pattern. The literature has
thus so far emphasised that, in spite of the increasing
recruitment of women, this pattern has been remarkably
stable (Flottorp, 1993; Korremann, 1994; Riska &
Wegar, 1993).
The recent studies on women in medicine should be
seen as a part of more general interest in what happens
when women move into arenas that have previously
been dominated by men. During the past 15–20 years,
increasing attention has been paid to such questions.
Several studies have thus helped to give valuable insight
into the situations that may arise when women enter
male dominated employment (Acker, 1989; Crompton &
Sanderson, 1990; Reskin & Roos, 1990; Kvande &
Rasmussen, 1990). Reskin and Roos (1990) discuss three
possible ways in which women may enter previously
male dominated arenas: (1) True integration, i.e. that
women are accepted on an equal footing with men, in
the same field of work, with the same tasks, and with
equal career possibilities; (2) Creation of ghettos }
which occurs when women and men with the same
professional title work in different fields in the same
profession, for example, when there is a systematic
difference in work organisation affecting which jobs they
have, or when they carry out different tasks in the same
field; (3) Re-segregation, i.e. professions that were
previously dominated by men gradually change and
become chiefly dominated by women. Re-segregation
can occur in a whole professional group or in parts of it,
for example in one or several specialties in medicine. It
 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
should be pointed out that creation of ghettos and re-
segregation are not mutually exclusive, but represent
different sides of the same phenomenon. Changes in the
gender composition of a profession is an ongoing
process, and what seems to be real integration at one
time can later turn out to be a step on the road towards
complete re-segregation.
Having data on two cohorts, we can now ask if the
effect of the increased recruitment of women into
Norwegian medicine from the 1970s to the 1980s has
resulted in true integration or not. Do women choose
the same specialties and professional fields as men
trained at the same time, or can we distinguish patterns
of a re-segregation of professional fields, possibly
creation of ‘‘ghettos’’ in some areas?
Material and method
This study is based on two sets of data, one derived
from the Physician Master File of the Norwegian
Medical Association on two cohorts of doctors,
authorised in 1970–73 and in 1980–83 respectively, and
the other from a questionnaire on doctors’ career. The
questionnaires were mailed to all doctors authorised in
Norway in the period 1980–83. Table 1 shows the total
number of doctors and the percentage of women and
men in the two sets of data on which the study is based.
The Physician Master File is collected by The
Norwegian Medical Association. It is continuously
being updated as regards information on place of work,
type of job, recognition as a specialist, working hours,
etc. I was permitted to collect the data relevant to my
study as from 1 March 1998. Ideally, the data on the
1970s cohort should have been backdated 10 years, to
March 1988, i.e. to a date when the oldest doctors had
had an equally long period to make their choice as the
1980s cohort had in March 1998. This has only been
possible in some cases, and, where nothing else is stated,
the data are from March 1998.
However, as the Master File only gives information
about the degree and types of specialisation, but nothing
about why some doctors choose not to specialise, I had
to supplement with another set of data. At the end of
1996 I carried out a comprehensive study on the career
Table 1
Doctors authorised 1970–73 and 1980–83, according to gender (%) (N=total number of doctors)
Doctors authorised 1970–73
(Norwegian Medical Register)
Women 15
Men 85
Total 100 (N=1202)
335
and family lives of doctors authorised in 1980–1983. The
questionnaire covered detailed questions on their
occupational history as well as questions on social
background, education, present job, specialisation, and
motive for choice of medical field. The questions to the
non-specialists on their reasons for not choosing to
become a specialist are relevant to this article.
1719 doctors received the questionnaire. 67% an-
swered the questions, the response rate being a little
higher among women than men. A slightly higher
percentage of women was found among those who
answered the questionnaire than that found in The
Norwegian Medical Association’s Master File on
doctors authorised in 1980-83, but otherwise the data
were representative as regards age. The average age (at
the end of 1997) was 54.8 years in doctors authorised in
1970–73, and 45.6 years in those authorised in 1980–83.
Differences between groups are described by bivariate
analysis with chi-squared test. All the statistical calcula-
tions were carried out by SPSS, version 8.0.
Results
Degree of specialisation
The comparison of the degree of specialisation of the
two cohorts was based on approximately the same time
of exposure. The years of calculation were 1988 and
1998 for the 1970 and 1980 cohorts respectively. Thus,
both cohorts had the same time to specialise, about 15–
18 years. The results show a surprisingly high degree of
specialisation in both cohorts. The prevalence of
specialisation 15–18 years after authorisation was very
similar in the two cohorts: slightly less than 80% of the
doctors were specialists at this time of their career. The
gender differences were minimal. When looking at the
1970 cohort 10 years later, in 1998, the degree of
specialisation has increased by approximately 10%,
slightly more among female than male doctors, the
degrees of specialisation being 91% and 85% respec-
tively, (see Table 2), i.e. some doctors specialise rather
late in their career.
The percentage of the specialists who are women
corresponds approximately to the percentage of women
Doctors authorised 1980–83 Doctors authorised
(Norwegian Medical Register) 1980–83 (Questionnaire)
24 28
77 72
101 (N=1826) 100 (N=1142)
336 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
Table 2
Total number of doctors and percentage of female and male specialists among all Norwegian doctors and those authorised as doctors
in 1970–73 and 1980–83. 1 March 1998
All doctors
Women
Total number of doctors 4270 (28%) 10,814 (72%) 184 (15%)
Percentage who were specialists on 1 March 1998 41% 66%
in the cohorts in question, 16% and 23%, respectively.
The increased proportion of female specialists and the
simultaneous growth in the total number of female
doctors have thus resulted in both a better supply of
female specialists in different fields and an increased
absolute number of female colleagues in most special-
ties.
An increasing number of women thus become
specialists, and today just as often as men. However,
men in both cohorts still specialise in more than one
specialty more frequently than women. The average
number of specialties covered by the male specialists in
the 1970–73 cohort was 1.4, compared to 1.2 among the
female specialists (p50.001). In the 1980–83 cohort, the
corresponding averages were 1.3 and 1.2 (p50.001).3
Doctors with more than one specialty include both those
who have continued their specialisation in a subspeci-
alty, e.g. continued from general surgery to gastroenter-
ology or from general medicine to heart diseases, and
those who change specialty completely, e.g. from general
surgery to obstetrics and gynaecology.
Comparing choice of specialties made by the 1970 and
1980 cohorts
Looking at first specialty, the women’s choice was
more expansive in doctors authorised early in the 1980s
than in those who had been authorised ten years before.
3
The exposure time for the 1970 cohort is about ten years
more than for the 1980s cohort, i.e. the calculation was made in
March 1998.
4 and 1980 cohorts, the main tendency was that, parallel
From 1985 there were 42 specialties to choose between,
compared to 32 in 1960 and today the number of specialties are
43, of which 14 are regarded as subspecialties of surgery and
general medicine. Both cohorts in this study faced the same
number of main specialties at the time of their decisions.
However, during the period from 1970 to 1980 the number of
subspecialties increased by three. The number of specialities is
about the same as in Denmark, while there is considerable
higher level in Finland and Sweden (Nordic Medical Associa-
tion 1999). When modernisation of the health services first
started to make headway in Sweden, the health services rapidly
became more specialised and connected with institutions to a
greater extent than in Norway (Berg 1980).
Doctors authorised Doctors authorised
1970–73 1980–83
Men Women Men Women Men
1018 (85%) 430 (24%) 1396 (76%)
91% 85% 78% 79%
The women of the 1970 cohort were found in 27 of 43
specialties, women authorised ten years later could be
found in 34 of 43 specialties 4 (see Table 3). For example,
they had now entered surgery. Otherwise, the great
increase in specialists in general practice was the most
marked difference between the two cohorts. Also,
regardless of being specialists or not, the percentage
working in general practice was twice as high in doctors
authorised in 1980–83 as in those authorised ten years
earlier, i.e. 38% and 19%, respectively. In general
practice, there were general practitioners with fixed
salaries, combined general practitioners, general practi-
tioners with private practices (with and without fixed
grants) and personal general practitioners.5 In both
cohorts, there was a tendency for women to choose
general practice with a fixed salary more frequently than
men did, but the difference was not statistically
significant, probably because there were too few women.
However, when all the professionally active doctors in
Norway (1 March 1998) were included, the difference
was significant: of those working in primary care
(general practitioners), 43% of the women and 33% of
the men were in fixed salary jobs.
Gender distribution within the various specialties
To examine possible changes in the gender distribu-
tion within specialties, the specialty in which the doctors
had their main employment 1 March 1998 was
examined. Table 4 shows the proportion of women
doctors in the various specialties. Comparing the 1970
to a general increase of women doctors, there has also
been an increase in women within most specialties. The
5
In 1993, a trial arrangement of personal general practi-
tioners was started in four municipalities. This meant that each
doctor was responsible for a list of a concrete number of
patients, i.e. a clearly defined patient population. Each patient
has a personal GP to consult. From year 2001, all the
municipalities in Norway will introduce the patient list system.
Remuneration will be changed from fixed grants to remunera-
tion according to the length of the list, including special
arrangements for certain groups of patients.
 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343 337

Table 3
Choice of speciality (1st main speciality), according to gender (%)

Doctors authorised 1970–73 Doctors authorised 1980–83

Speciality: Women Men Women Men

General practice 16.2 15.2 36.7 36.7

Anaesthesiology 4.8 3.7 3.3 6.0
Occupational medicine 3.0 0.9 4.8 1.5
Child and adolescent psychiatry 5.4 0.6 3.0 0.3
Paediatrics 6.6 6.1 4.5 2.6
Obstetrics and gynaecology 10.8 5.9 7.5 2.7
General surgery 0.0 14.0 3.6 10.3
Other fields of surgerya 0.0 0.8 0.3 0.8
Internal medicine 7.8 17.1 5.4 11.0
Other fields of internal medicineb 6.0 7.2 5.1 5.2
‘‘Laboratory disciplines’’ 7.7 4.2 4.2 2.9
Psychiatry 15.6 7.5 13.1 8.5
Radiology 8.4 5.7 2.6 2.7
Community medicine 1.8 5.0 2.4 3.4
Ophthalmology 4.7 3.4 2.6 2.3
Otorhinolaryngology 1.2 2.7 0.9 3.1
Total (non-specialists are not included here) 100.0 N=167 100.0 N=866 100.0 N=335 100.0 N=1105
a
Covers the following in the 1970–73 cohort: surgery, neurological surgery, and plastic surgery. In doctors authorised in 1980–83 it
also covers paediatric surgery, gastroenterological surgery, blood vessel surgery, orthopaedic surgery, and chest surgery.
b
Includes dermatology and venereal diseases, neurology, rheumatology, and oncology.

Table 4
Percentage of women specialists in different fields, total and according to authorisation year. (The figures within parentheses are the
total number of doctors in each specialties)

Specialty practised in main job Percentage of women, Percentage of women, Percentage of women,
on 1 March 1998 all active doctors authorisation year 1970–73 authorisation year 1980–83

General practice 23 (2157) 17 (151) 23 (491)

Anaesthesiology 17 (617) 19 (42) 14 (79)
Occupational medicine 32 (167) 31 (16) 43 (40)
Paediatrics 24 (417) 19 (58) 36 (39)
Child and adolescent psychiatry 64 (87) 73 (11) 87 (15)
Obstetrics and gynaecology 31 (514) 26 (69) 43 (56)
General surgery 8 (425) 0 (34) 18 (44)
Other fields of surgerya 5 (132) 0 (19) 7 (15)
Surgical sub-specialtiesb 2 (657) 0 (79) 5 (78)
General medicine 13 (540) 6 (51) 9 (64)
Other fields of medicinec 24 (655) 12 (74) 23 (84)
General medicine subspecialtiesd 10 (722) 9 (105) 17 (77)
‘‘Laboratory disciplines’’ 22 (896) 25 (52) 37 (38)
Psychiatry 29 (888) 27 (101) 33 (144)
Community medicine 12 (371) 9 (54) 14 (65)
Ophthalmology 17 (335) 22 (37) 26 (35)
Otorhinolaryngology 7 (288) 8 (24) 8 (36)
Total (non-specialists are not included here) 19 (9878) 16 (1040) 23 (1440)
a
Covers the following: paediatric surgery, gastroenterological surgery, blood vessel surgery, chest surgery, urology and orthopaedic
surgery.
b
Covers the following: dental, oral and maxillofacial surgery, neurological surgery and plastic surgery.
c
Includes dermatology and veneral diseases, geriatrics, neurology, rheumatology and oncology.
d
Covers the following: blood diseases, infectious diseases, cardiology, endocrinology, gastroenterology, lung diseases, and kidney
diseases.
338 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
exceptions were anaesthesiology, where there was a
decrease, and radiology and otorhinolaryngology, where
the percentage of women was almost unchanged. In
both cohorts, women were over-represented in several
disciplines, particularly in child and adolescent psychia-
try, obstetrics and gynaecology, occupational medicine,
and paediatrics.
Even so, women were still under-represented in
several specialties. Although eight of a total of 44
surgeons in the 1980 cohort were now women (18%),
fewer women than men had entered other major surgical
specialties such as plastic surgery, neurological surgery
or dental, oral and maxillofacial surgery (one out of 15 is
a woman). Women seem to be particularly hesitant to
specialise in surgical sub-specialties, only four of 78
doctors in the 1980s cohort working in surgical sub-
specialties had done so (5%). In general medicine, which
is the other large hospital specialty in Norway, the
picture is more complex. Seen as a whole, there has been
an increase of women in general medicine. The number
of doctors who were working in general medicine sub-
specialties was, however, so low that it is pointless to
discuss details regarding percentages. For example,
amongst specialists in cardiology, there were three
women of a total of 25 in the 1980 cohort, against one
of 21 in the 1970 cohort.
Thus, the main picture is that women educated early
in the 1980s avoided some specialties less than women
educated 10 years previously. This is interesting, because
it undermines the hypothesis that only very small
changes have taken place in women’s choice of
specialties as increasing numbers of women have started
to study medicine over the last couple of decades.
However, women were still missing } or strongly under-
represented } in several specialties. One indicator that
this will persist is found in the survey presented to
doctors authorised in 1980–1983. The doctors who are
becoming specialists today, either for the first time, or in
addition to existing specialisation, continue to restrict
themselves to certain fields. Of the 86 doctors (56 men
and 30 women) who were in the process of becoming
specialists for the first time, about three-quarters of the
women had chosen either general practice, psychiatry, or
occupational medicine, while the men had chosen a
specialty from a larger spectrum of specialties, with the
main emphasis on general practice. This picture is not
disturbed by the doctors’ re-specialisation either. Of the
48 doctors (13 women and 35 men) who were re-
specialising, more than half the women had chosen
psychiatry, and (with one single exception), none went
into general medicine, surgery, or the sub-specialties of
these disciplines. Almost half the men, however, had
chosen to re-specialise in these specialties. The data
regarding renewed specialisation in some form or other
thus indicate that even though women in the 1980
cohort were more expansive in their choice of specialties
than their younger sisters, they still covered fewer
specialties than their male colleagues, they concentrated
on some ‘‘traditional’’ disciplines, and less frequently
chose to sub-specialise.
Why do some doctors choose not to become specialists?
In the questionnaire presented to doctors authorised
in 1980–83, only 8% were neither specialists nor in the
process of becoming specialists. The variation was fairly
large between professional fields with regard to how
many of the doctors were not specialists: 18% of the
doctors working in ‘‘laboratory disciplines’’ 6, 13% of
those in community medicine and 9% of those in general
practice were not specialists. On the other hand, there
were only few non-specialists among those working in
disciplines as surgery, general medicine, obstetrics and
gynaecology, and paediatrics. The non-specialists were
asked to give reasons for why they had chosen not to
become specialists by responding to a set of statements
(fits well, fits to some extent, does not fit), (see Table 5).
The modal answer of both genders was ‘‘to specialise is
not necessary for my present job’’. With one important
exception, there was no significant difference between
women and men when they gave reasons for their choice
of not becoming specialists. More than three-quarters of
the women said that it had been difficult to combine
becoming a specialist with family responsibilities, while
this only applied to less than one third of their male
colleagues. Twice as high a percentage of women as of
men attached importance to moving to another geo-
graphical area because of partner’s work. The difference
was not significant.
The fact that female non-specialists put such great
emphasis on the problem of combining specialist
training with responsibility for children and family
raised the question of whether they had more children
than those who became specialists, or whether they had
been/were more often alone with responsibility for the
children? Data from the questionnaire show that 68% of
the non-specialist women had three or more children
compared with 45% of the specialists, the median values
being three and two children respectively (p50.01).
To sum up, Norwegian women doctors authorised in
1970–73 and in 1980–83 specialise to a very high degree
and just as much as their male colleagues, but their
pattern of specialisation continues to be different.
However, over the last 10–15 years, changes in the
specialisation pattern have taken place that can be
summarised in four points: (1) Proportionately more
doctors authorised in 1980–83 than those authorised 10
years previously have chosen general practice as their
6
‘‘Laboratory disciplines’’ is a collective term covering fields
such as clinical chemistry, medical biology, medical genetics,
clinical pharmacology, and pathology.
 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
Table 5
Reasons for not becoming a specialist. The percentage who answered ‘‘Agrees well’’ among doctors authorised in 1980–83, according
to gender. (The figures within parentheses are the total number of women and men, respectively)
How well do the following statements agree
with the reason that you have chosen not to be a specialist?
Not necessary for my present job
Took too long
Difficult to get the job I wanted
Difficult to combine with family responsibilities
Had to move house because of partner’s job
main specialty. This applies not only to the women, but
also to the men. (2) Women authorised early in the 1980s
spread their choice of specialisation over more fields
than their female colleagues of 10 years earlier did.
Younger women have started to enter general surgery
and general medicine, although still not as often as men.
(3) There are tendencies towards an increasing female
concentration in some professional fields such as
obstetrics and gynaecology as well as paediatrics. (4)
The percentage of women in anaesthesiology has
decreased: women of the 1980 cohort more seldom
choose anaesthesiology than colleagues educated a
decade earlier.
Discussion
This study has demonstrated changes in women’s
pattern of specialisation that have not been found in
earlier cross-section studies. This is probably because
changes in specialisation patterns of younger cohorts
only have a small effect on the overall picture of the
whole population, and that it takes time to make a
career. While doctors spend an average of nine years
becoming a specialist, and the majority of those
specialising do so within a period of 5–15 years after
being authorised, it is only now, during the last half of
the nineties, that we can fully appreciate the results of
the choices made by doctors authorised during the first
half of the 1980s. A comparison of the pattern of
specialising in two cohorts of doctors probably provides
a better foundation than cross-sectional data covering
all doctors. It makes it easier to capture changes, and
not least to see them in the light of the contemporary
changes both in society at large and in the health
services.
Two features of the development are especially
important. In the first place, during this period ideas
of gender equality permeated Norway, especially regard-
ing education and employment. With more, and ever
higher, education, women also started to expect equal
possibilities in their careers. This also applied to women
339
‘‘Agrees well’’
Women Men Chi–squared p-value
56 (18) 62 (55) 1.54 n.s
19 (16) 20 (55) 0.02 n.s
7 (15) 9 (54) 0.98 n.s
78 (18) 31 (54) 16.53 0.000
47 (17) 23 (55) 3.45 n.s
in medicine, who entered a gender-segregated occupa-
tional structure. Secondly, great changes were taking
place in the health services, influencing doctors’ career
possibilities and opportunity structure. The 1970s were
the hospitals’ decade, with a great increase in the
number of jobs for doctors; the 1980s were the decade
of primary health care. The number of jobs in the
primary health services increased substantially, salaries
and working conditions for primary doctors improved,
and the prestige of general practice increased both by its
connection with universities and because it became a
separate specialty. Contemporary changes of this kind
probably affect individual preferences, opportunity
structure, as well as closure mechanisms.
Women of the 1970 and 1980 cohorts specialise just as
much as their male colleagues
This contrasts with the overall picture of profession-
ally active doctors in Norway: in 1998, the degrees of
specialisation among all professionally active women
and men doctors were 41% and 66%, respectively. The
results also diverge from earlier findings both in Norway
(Arnesen et al., 1974; Steinsholt et al., 1990; Flottorp,
1993) and in Nordic countries (Riska & Wegar 1993).
However, it confirms a tendency we saw in those who
were recognised as specialists in 1993: the percentage of
women corresponded to the percentage of women
among doctors as a whole. A survey of Norwegian
doctors in 1993 also showed that the gender differences
as regards degree of specialisation were smallest in
doctors aged 45–54 years (Gjerberg & Hofoss, 1995).
Both structural and individual factors may be of
importance in explaining these findings. The overall
tendency of extensive specialisation shown by the results
is an expression of a general tendency to increasing
specialisation that has taken place among Norwegian
doctors in recent years. This probably reflects the
substantial medical-technological development, the stea-
dily increasing demands for specialised medical services,
as well as professional interests. Moreover, the fact that
general practice was recognised as a separate specialty in
340 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
1984 and that specialists are better paid than non-
specialists has also contributed to the increasing
specialisation.
However, the tendency among women to specialise
just as much as men is probably not only due to these
changing conditions, but also to changing expectations
of equal opportunities. Women doctors belonging
to the 1970 and 1980 cohorts have made the same
investments in their education as their male colleagues,
based on expectation of equal financial returns.
They are thus expecting and planning a life-long career,
knowing that specialisation pays. The majority of
women doctors are no longer satisfied with being an
‘‘ordinary’’ doctor. Knowing that specialisation gives
the best profit, women doctors make this investment just
as often as their male colleagues do, although the fields
of specialisation differ.
Doctors of the 1980s } ‘‘the GP-generation’’
The expansion of the primary health services has
attracted twice as many doctors from the 1980 cohort as
from the 1970 cohort, with equal numbers of women
and men. It is not possible to analyse these changes in
the pattern of specialisation without considering the
structural changes in health care that have taken place.
The large recruitment to general practice among the
youngest doctors should obviously be seen in the light of
the health reform policies that took place in the primary
health services from the middle of the 1970s and
onwards. These culminated in the Municipal Health
Services Act of 1982, and in the recognition of public
health and general practice as separate specialties in
1984/85. Unlike the expansion of jobs in the hospital
specialties in the 1970s, the growth in general practice
seems to have had an integrating effect on women
doctors authorised in 1980–83, in that they became
specialists as often as men. The reforms enabled both
better regulation of the day’s work with the possibility of
fixed hours and moderate irregular hour duty. This was
especially attractive in phases of life with heavy
requirements regarding care of children and family, as
illustrated by a doctor who was torn between general
medicine and general practice:
I have switched between general practice and general
medicine. In general practice I have fixed working
hours, I do not have to be on duty outside working
hours as others are interested in this, and this
organisation of work gives me more time with my
family. My choice of general practice is primarily
based on consideration for my family. However, I am
very interested in general medicine, and have at times
worked in general medicine wards. I have always
experienced my periods of work here as a strain on
the family because of the great pressure of work
(respondent in questionnaire to doctors authorised in
1980–83).
The difference in choice of specialty between the
cohorts from the 1970s and 1980s may also indicate that
structural changes, for example the establishment of a
new specialty, increasing the number of jobs within
specialties, and the introduction of a new remuneration
system, have an important effect on the composition of
the medical profession. Such changes, however, primar-
ily affect those who are about to make a choice, i.e.
relatively early in their careers. This means that the
changed opportunity structure and the status elevation
of general practice early in the 80s primarily affected
doctors who were at the start of their careers much more
than others and cannot be expected to continue ‘‘into
the sky’’.
Although general practice has managed to attract
equal numbers of men and women, the detailed picture
is more varied. Women have chosen fixed salary jobs
(municipal), while the men are over-represented in
private practice. We thus see tendencies towards a
concentration of women in certain jobs in the primary
health services, both in the material examined in the
present article and in Norwegian doctors as a group.
This agrees with Finnish studies where Riska and Wegar
(1993) found that women were more often found in fixed
salary jobs, and in jobs that usually lacked indepen-
dence: little autonomy in the job, routine work, and low
pay and status in the medical hierarchy. All the same, I
do not find it correct to characterise this as a creation of
ghettos as Riska and Wegar do; the concentration of
women in these jobs is too low for that. In Norway,
doctors in private practice are better paid than
colleagues working in fixed salary jobs. However, these
jobs are better regulated, i.e. working hours on duty are
more predictable, and thus more compatible with
domestic and family circumstances.
Women doctors of the 1980s are more expansive: change
of preferences and closure mechanisms?
The youngest cohort of female physicians chose a
broader spectrum of specialties than their older collea-
gues. This may be connected to the different starting
points facing the two cohorts. Although both
‘‘generations’’ of women have witnessed and been part
of the same substantial changes in society, i.e. changes in
equal status ideology and practical politics, these
changes occurred at different times in their lives. Women
who became fully qualified doctors early in the 1970s
may well have taken an active part in the fight for equal
status of the 1970s, but those who qualified 10 years
later were more likely to have been brought up on equal
status ideas. The 1970 cohort grew up and went through
their training under more ambiguous expectations of the
 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
role of women than those born 10 years later, and have
probably been affected by this in their choices regarding
the future. The difference between these women and
their contemporaries was far greater than that experi-
enced by women authorised a decade later. To become a
doctor, or even more a specialist, might thus have been
recognised as a very good return of their investment in
higher education. However, to specialise in surgery or
general medicine, the most traditionally male dominated
areas may still have been recognised as being too
difficult for women doctors of the 1970s. Thus, in
deciding on their career, most of them chose specialties
that were compatible with actual or future domestic
responsibilities.
However, individual ‘‘constraints’’, such as family
preferences cannot fully explain the fact that women
doctors authorised early in the 1970s very seldom chose
a career in the prestigious, expanding hospital system.
The fact that women doctors are represented in their
expected proportion in the specialties of both gynaecol-
ogy/obstetrics and paediatrics, which involve just as
demanding and irregular work as surgery and general
medicine, indicates the existence of supplementary
explanations. It is thus probable that male exclusionary
strategies were more extensive in the 1970s than ten
years later, thus preventing women doctors from
choosing a career in hospital medicine, such as surgical
specialties. Women specialists in surgery have reported
different kinds of male exclusionary practices on their
way towards completing surgical training: lack of
opportunity for gaining enough and adequate surgical
experiences, not being considered for appointments,
deficient counselling from patrons, being ridiculed, etc.
These women had managed to become specialists in
surgery despite exclusionary strategies which gave pre-
ference to males, but knew others who had quit before
completing their training (Nore, 1993). The existence of a
‘‘male chauvinistic culture’’, preventing women from
choosing surgical specialties, is a widely held belief
among Norwegian doctors: 30% of Norwegian doctors
thought this was true (Gjerberg & Hofoss, 1998).
However, the increasing tendency of women to choose
a broader spectrum of specialties is probably not only
due to changing individual preferences and closure
mechanisms. During the last years of the 1980s and
the first part of the 1990s in Norway there was
increasing dissatisfaction with the salaries and working
conditions of hospital doctors, resulting in temporary
problems in recruiting doctors. This may have made it
easier for women doctors to get a position in hospitals
when they applied for it.
Even though women of the 1980 cohort have moved
into disciplines such as surgery and general medicine,
they are a long way from being fully integrated into
these specialties. The data indicate that integration takes
time and occurs gradually: although some of the
341
youngest women have chosen surgery, only a very few
have continued with sub-specialties. This is probably
due to an interaction between individual and structural
factors. Women doctors choosing prestigious specialties
like surgery and general medicine have had very good
returns from their investment in medical education.
Further sub-specialisation may thus not be recognised as
necessary. However, it is just as important that sub-
specialisation not only entails more years of training,
but perhaps moving house again because a large part of
the training must take place in university or regional
hospitals. Sub-specialisation takes place rather late in
their careers. The chances of being well established with
a family and partner who is also working are greater
now than they were at the start of specialist training,
making it more difficult to move house. However, it
might be too early to claim that women doctors of the
1980 cohort very seldom sub-specialise. As some doctors
continue to specialise rather late in their career, it is still
possible that women doctors will continue their specialty
into sub-specialisation, postponing the training to a
more appropriate period of their lives.
Towards re-segregation of some medical disciplines?
In Norway, as in other countries, child and adolescent
psychiatry has a long history of female over-representa-
tion. Today, however, there is much to indicate that the
trend we see in the doctors in the 80s cohort towards an
over-representation of women in obstetrics and gynae-
cology, paediatrics, occupational medicine, and psychia-
try will continue in the years to come. In June 1998, 61%
of paediatric and 75% of gynaecological non-specialist
junior registrars were women (The Norwegian Medical
Association, 1998). Although it is not certain that all of
these will become specialists, it is a clear indication of
further concentration of women in these disciplines. This
is probably due both to individual preferences and to
working opportunities. As far as obstetrics and gynae-
cology and paediatrics are concerned, identification with
own gender and thus an interest in matters related to
reproduction, gynaecology, and caring for children
probably helps make these specialties particularly
attractive to women. One other reason that may
contribute to so many women choosing these fields is
the possibility of running a private practice. This means
you do not have to be on call outside working hours
(unlike working in hospitals). Being on call outside
working hours probably means more to women than to
men when choosing a specialty (Gjerberg & Hofoss,
1998).
What is happening to anaesthesiology?
The decreasing proportion of women in anaesthesiol-
ogy among the 1980 cohort mirrors the development
342 E. Gjerberg / Social Science and Medicine 52 (2001) 331–343
over the last 25 years. From 1971 to 1998, the overall
proportion of women in Norwegian anaesthesiology has
decreased from 26% to 17%. This development is
probably mostly due to changing contextual factors at
different levels. During the last ten to fifteen years there
has been a development in anaesthesiology with
increased responsibility for acute medicine in the
hospitals as well as pronounced technological develop-
ment in the field. In Norway, anaesthesiologists also
staff the air ambulances. Two factors may have
influenced the number of women anaesthetists. In the
first place, the expansion of the field has resulted in a
higher work load on calls, and thus making it more
problematic to balance domestic and occupational
obligations. These changing working conditions may
have influenced the preferences of women doctors more
than their male colleagues (Gjerberg & Hofoss, 1998).
Secondly, the changing position of anaesthesiology in
the hospitals and the technological development has also
resulted in increased prestige of the field. Compared to
most Nordic countries where anaesthesiology is con-
sidered to be a field characterised by routine and fairly
low prestige (Riska & Wegar, 1993; Korremann, 1994),
this is not the case in Norway. Album (1991) found that
anaesthesiology was recognised as one of the most
prestigious specialties. The increased prestige of the field
has probably changed the recruitment, i.e. more male
doctors are attracted to the field.
Conclusion
In spite of the relatively rapid increase in the number
of women, the medical profession is still in many ways a
gender-segregated professional group, although impor-
tant changes are taking place. The changes are, however,
far from unequivocal. All in all, Reskin and Roos’ set of
concepts seem to be a useful tool in describing what may
happen when women enter an occupation that was
earlier dominated by men. In this article, their concepts
of integration, ghettoisation and re-segregation are used
to illustrate that the changes in the pattern of
specialisation develop along various lines, dependent
on which fields we are looking at. In general practice, for
example, we see that young women are integrated on an
equal footing with men, though it should be noted that
there are signs of female dominance in the public jobs.
However, these tendencies are hardly strong enough to
be characterised as ghettoisation. It is not possible to
understand the gendered division of specialties and the
changes in established patterns until they are related to
contemporary changes both in health care and in the
society. The great changes in priority for general
practice demonstrate very clearly that changing health
care policies with the subsequent changing working
conditions substantially affect both female and male
doctors’ choice of specialty. In other fields of medicine,
such as obstetrics and gynaecology and paediatrics, we
see a tendency towards re-segregation, i.e. these special-
ties are in a process of being dominated by women. And
in some fields of medicine, women are still either not
represented at all or strongly underrepresented.
Although there are thus great variations between
different professional fields, this study gives a more
optimistic picture than earlier studies, indicating that
women may approach an equal status to men in the
choice of medical specialty.
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