As I navigated my own health, I learned how unfriendly and helpful conventional medicine could be to women.
This article is not meant to be derogatory to medicine or medical doctors in any way. As a female biomedical researcher who navigated the health care system, I went through years of anger and distrust in conventional medicine. But after a few years as a medical writer, I became grateful for what conventional medicine can and has been able to accomplish. What I’m trying to do here is to compassionately raise awareness for this gender inequality in healthcare. It’s not like doctors aren’t doing their best, but medicine is an imperfect art, science, and institution. Most importantly, the responsibility falls on us – the patients – to ensure that we are getting the right care and do what it takes to achieve the desired health outcomes.
Why Is There Gender Inequality in Healthcare Treatment?
Women commonly get ignored or downplayed as we seek care. We wait longer to receive treatments for the same complaints compared to men. We’re more likely to get prescribed sedatives and psychiatric medications for pain,1,2 and overall to be told statements like:
- The notion of “hysteria” from Ancient Greek and throughout the 18th-19th centuries. Back then, doctors attributed female ailments and any symptoms that make men uncomfortable to hysteria, which was treated by stimulating the clitoris. Part of this had to do with the patriarchal notion that women were less than men.
- Remnants of patriarchal and culturally influenced judgments and practices. Medicine is not only a science but also a product of evolving social constructions and power relations dependent on their historical context.3 For example, some physicians still scold female patients who seek help for their sexual dysfunction. Sometimes, gynecologic complaints are blamed on the patient’s character without a medical basis. Some procedures, such as adding an extra stitch (husband stitch) to tighten the vagina while repairing childbirth tears, are done without the patient’s knowledge or consent.
- Lack of emphasis on emotional intelligence in medicine. Doctors of both genders are poorly equipped to deal with their patients’, and perhaps their own, emotions. Throughout medical school and residency, they’re taught to remove emotions from the practice of medicine. They have no opportunity to grieve after each patient dies. It is nearly impossible to console a patient and do everything they need to do in a 15-minute and sometimes 3-minute appointment. This is bad both for doctors and patients.
Medicine has been created for men and by men. As a result, we know much less about the female body and how our bodies respond to treatments. Also, medicine often defaults to filling the knowledge gaps with hysteria narratives, especially for patients with complex health issues.3
Gender Bias in Biomedical Research
The gender bias isn’t specific to patient care; it is also prevalent in biomedical research. It wasn’t until the 1990s that clinical trials started including women. Premenopausal women have fluctuating hormones that affect all aspects of our physiology, making it more difficult to design studies to address them.
Even preclinical studies, such as cell-based and animal studies, were more likely to be limited to males due to the potential hormones-related variability. 8 out of 10 animal studies had a male bias. Also in animal studies that used animals, the ones that only used male animals outnumbered those with females by 5.5 to 1. Even in diseases that predominantly affect females, only 12% of studies used females or both sexes.4
Prior to 1994, women were excluded from early drug studies.5 In 2005, 8 out of 10 prescription drugs were withdrawn from the market because they caused side effects specific to women. The clinical trials involved mostly men and failed to discover these side effects prior to the drug approvals.6 In 1994, the NIH issued a guideline to include a full range of patients who would use the drugs in early-stage drug trials. They also now require NIH-funded to include both sexes unless the researchers can reasonably justify the unisex nature of the studies.
Research is now discovering more differences between men and women. We have different disease manifestations, drug responses, and pain sensations.7 There are numerous examples of how gender inequality in healthcare and biomedical research results in more deaths, disability, and prolonged suffering.
Example 1: Heart Disease in Women
It was once thought that heart attacks were men’s disease, but, in fact, heart disease kills many more women than men.8 It’s also the most common cause of death among women worldwide.9 Women experiencing heart attacks have milder and more atypical symptoms, such as nausea and jaw pain than men. These factors exacerbate the fact that women are likely to wait longer to receive care or to be sent home upon seeking care. As a result, about 35% of cases go undetected and untreated, so women are much more likely to die of heart attacks.8
Example 2: Drug Response
Ambien, the sleep medication, was approved in the early 1990s. Back then, women of childbearing age were kept out of drug trials because of the liability that the drugs could harm the fetus. As a result, decades after Ambien hit the market, it was realized that women took much longer to clear the drug from their system. Women who took the drug to sleep had higher morning blood levels of the drug than men, so they experienced significantly more cognitive impairment and got into car accidents in the morning. They are also more likely to have strange sleep behaviors than men using the same drug. By 2013, the FDA recommended half the dosage for women.10
Example 3: Endometriosis
Endometriosis is a painful debilitating condition that affects 1 in 10 women, and 30–50% of women with pain and fertility problems.7 Endometriosis symptoms may include painful menstruation, prolonged bleeding, pain with intercourse and urination, and digestive problems. Although it was first described in the 1800s, we still know very little about the cause, diagnosis, and treatments of endometriosis.
Currently, the only way to definitively diagnose endometriosis is laparoscopic surgery, which requires general anesthesia. The only accepted treatments for endometriosis include hormonal birth control or surgical resections. These are disease management, not cures, because these patients may experience recurrence.
In over 200 years, biomedical research has yet to find safer, less invasive, and more effective ways to diagnose and treat endometriosis. In addition, because laparoscopic surgery is the gold standard to diagnose and measure the severity of the disease, clinical trials for endometriosis have to rely on other endpoints such as pain severity. Therefore, it’s very difficult to prove that a treatment is effective for endometriosis in large-scale placebo-controlled trials, which is required to bring the treatment to market.
On average, it takes 7 years for a woman with endometriosis to be correctly diagnosed, with the range being 3.5–12.1 years.11 The diagnostic delay likely results from how women’s pain often gets ignored and women with difficult conditions are often called crazy. It is also common for endometriosis patients to receive patriarchal and culturally influenced comments and advice that have no medical basis.
These inequalities don’t only affect women; they have ripple effects throughout society. Women often play caretaking roles in their families, and their sickness affects the wellbeing of their entire families. Also, the need to withdraw approved medications from the market due to their female-specific side effects wastes billions of research dollars.
Why the Current Research Model Works Against Women
The current medical model relies heavily on randomized controlled trials and meta-analyses of well-controlled studies. While I understand the need to separate the treatment’s benefit from placebo effects, this model fails women for many reasons:
- The model favors monotherapy, such as studying single drugs or surgery at a time in isolation. However, multiple lifestyles and dietary factors in combination typically have bigger influences on disease outcomes.
- Randomized controlled trials assume that each participant is statistically identical. Obviously, every participant is different regardless of gender, but clinical trials on women are more subject to individual variability than men.
- Clinical trials can miss the forest for the trees by selecting the wrong endpoints or too stringent statistics.
- Accepted treatments for many women’s health problems, such as hormonal birth control, only control the symptoms without curing the real issues. When they get off birth control or try to get pregnant, the problems return. Unfortunately, this short-term “satisfactory” outcome tends to stunt research efforts into true long-term effective cures.
- Because research has largely neglected women, many effective treatments remain “unproven” due to the lack of research.
These problems are especially true for chronic diseases that disproportionately affect women, such as hormonal disorders, autoimmune diseases, pain disorders, Alzheimer’s disease, and psychiatric problems.
Proposed Solutions
Given the five reasons above, women are pretty much on their own with respect to our health. Obviously, we cannot expect the medical standard of care to take care of us. Medicine cannot even meet its own standards when it comes to taking care of women. Many of us are still left suffering in pain or sent home with misdiagnoses, sometimes to our deaths.
The future of women’s healthcare is going to involve precision medicine and integrative care. We need to be informed of our conditions, be aware of our own choices, and take charge of our data.
Tips for Communicating in a Typical Medical Appointment
- Appear calm, respectful, and confident. Don’t end your sentences in high pitches.
- If you suspect your doctor could be brushing you off or doing less than they should, ask “What is the basis behind this recommendation/statement/thoughts? Can you walk me through your thought process?”
- If you are diagnosed with a medical condition or a suspected one, be informed of the medical consensuses around it. Major medical organizations, such as the American College of Obstetricians and Gynecologists or the American Society of Reproductive Medicine published guidelines for medical doctors regarding tests, diagnoses, and treatments based on the latest evidence. [Note that I don’t recommend Internet health research on blogs that are targeted to consumers.] That way, you can tell if the doctor is following these guidelines. However, these guidelines are not meant to replace their clinical judgments and experience.
- Bring someone with you to witness your appointments.
- Don’t hesitate or wait to seek second and third opinions or change your doctor, especially if your conditions get worse over time. In general, you can’t trust that your doctor will have 100% of the solution or knowledge. You cannot trust that you’re getting the best treatment, that your problem will go away, or that you won’t experience side effects. This is applicable for people of both genders seeking healthcare.
Try Alternative Medical Models
If you are actively working on your health, a subscription primary care model may work better than the typical “pay-per-appointment” model. In these models, you pay a monthly fee for a monthly 1-hour appointment with your doctors and message them in-between with your questions. Some companies even have primary care doctors with lifestyle medicine interests, such as in ketogenic diets, biohacking, functional medicine, or athletic training.
It is also a great idea to see alternative health practitioners, such as naturopathic doctors, functional medicine doctors, and acupuncturists. They all take different approaches to support health building more so than treating specific health conditions.
Collect Data and Self-Experiment
We have very limited clinical data on the following:
- How the female body works, especially in fit women
- How our health outcomes may respond to drugs and lifestyle changes, especially when all of these factors interact with each other
- How to support hormonal changes throughout our lives, such as menstrual cycles, pregnancies, and menopause
To fully take care of yourself and optimize your health, there is no way around biohacking, or continually self-experimenting. Every woman is a unique snowflake with her own hormonal fluctuations, genome, epigenome, mind-body connections, health struggles, and lifestyle preferences. It would take a few hundred more years for studies to fully catch up with all the things that can deliver the health outcomes we desire.
MyJourney.science is a great tool for scientific self-experimentation and data collection for this purpose.
References
1. Chen, Esther H., Frances S. Shofer, Anthony J. Dean, Judd E. Hollander, William G. Baxt, Jennifer L. Robey, Keara L. Sease, and Angela M. Mills. “Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 15, no. 5 (2008): 414–18. https://doi.org/10.1111/j.1553-2712.2008.00100.x.
2. Calderone, Karen L. The Influence of Gender on the Frequency of Pain and Sedative Medication Administered to Postoperative Patients.” Sex Roles 23, no. 11 (1990): 713–25. https://doi.org/10.1007/BF00289259.
3. Young, Kate, Jane Fisher, and Maggie Kirkman. “‘Do Mad People Get Endo or Does Endo Make You Mad?’: Clinicians’ Discursive Constructions of Medicine and Women with Endometriosis.” Feminism & Psychology 29, no. 3 (2019): 337–56. https://doi.org/10.1177/0959353518815704.
4. Karp, Natasha A., and Neil Reavey. “Sex Bias in Preclinical Research and an Exploration of How to Change the Status Quo.” British Journal of Pharmacology 176, no. 21 (2019): 4107–18. https://doi.org/10.1111/bph.14539.
5. Liu, Katherine A., and Natalie A. Dipietro Mager. “Women’s Involvement in Clinical Trials: Historical Perspective and Future Implications.” Pharmacy Practice 14, no. 1 (2016): 708. https://doi.org/10.18549/PharmPract.2016.01.708.
6. Holdcroft, Anita. “Gender Bias in Research: How Does It Affect Evidence-Based Medicine?” Journal of the Royal Society of Medicine 100, no. 1 (2007): 2–3. https://doi.org/10.1177/014107680710000102.
7. Hoffmann, D. E., and A. J. Tarzian. “The Girl Who Cried Pain: A Bias against Women in the Treatment of Pain.” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 29, no. 1 (Spring 2001): 13–27. https://doi.org/10.1111/j.1748-720x.2001.tb00037.x.
8. Giardina, E. G. “Heart Disease in Women.” International Journal of Fertility and Women’s Medicine 45, no. 6 (2000): 350–57. https://www.ncbi.nlm.nih.gov/pubmed/11140544.
9. Woodward, Mark. “Cardiovascular Disease and the Female Disadvantage.” International Journal of Environmental Research and Public Health 16, no. 7 (2019). https://doi.org/10.3390/ijerph16071165.
10. Roy, Sree. “Ambien Dosage for Women Adjusted in 2013, But Sex Bias in Drug Trials Persists to This Day,” August 21, 2020. https://www.sleepreviewmag.com/sleep-treatments/pharmaceuticals/prescription-drugs/ambien-women-adjusted-sex-bias-persists/.
11. Arruda, M. S., C. A. Petta, M. S. Abrão, and C. L. Benetti-Pinto. “Time Elapsed from Onset of Symptoms to Diagnosis of Endometriosis in a Cohort Study of Brazilian Women.” Human Reproduction 18, no. 4 (April 2003): 756–59. https://doi.org10.1093/humrep/deg136