Authored By Rania Jardak
On our second class of Ethics, here at the university of Pavia, we have been told: “In medicine, there are no cause-effect; there are causes AND effects”. I invite you to think about the causes and effects of every cell function and its physiological manifestation – but I also invite you to think about the causes AND effects of every diagnosis, of every medical assumption, of every waiting room attitude. I extend my invitation further to also think about how the causes AND effects of a same nature or expression affect for different groups of people. We must be able not only to apply our knowledge onto different patients, but we must be able to be critical about the very application itself.
Our lifelong exposure to ideas stored as biased information serves as a reservoir for our unconscious processes. This tends to be translated into biased attitudes and reactions when we are not actively being consciously unbiased. Ceding to bias is an “human trait”, one that would be exhausting to eliminate from our every thought process, but a trait that can cause harm when you know just enough science and that you are culturally being attributed just enough authority to have the power to influence another being’s health – such as when you are a healthcare provider. Now let us be clear – medical professionals have the best interest of the patient, all patients, in mind. This may however not suffice to beat biases that are inherited from higher levels (historical, institutional, societal, academical) of the medical field.Bias occurs in medicine not by deliberate malpractice or by lack of good will, but it occurs due to broader socio-political stratification of society in relation to gender, race, age and other variables that, in the most fortunate of situations, provide clues and context to explain a pathological manifestation but that may, more often than wished for, blur the true origin of an ailment.
Gender-bias – the unintended but systemic neglect of either men or women – has been extensively documented in medicine. The health of both sexes is influenced by biological factors including but not confined to their reproductive characteristics. Added to these biological differences are socially-constructed gender characteristics that shape the capacity of both men and women to realize their full potential for health. There are serious and important consequences of gender bias for women’s lifetime health.
Modern medicine became what we know today based on physiological premises about the body and metabolism of the carefully-studied 70kgs white male. Pathology research and medication development has been tailored around his unique body mass composition and cell metabolism. If you are anyone else than him -say, a woman- a simple equation should be able to translate medical research onto your unique phenotype. In default of this equation, you could still decide to metamorphose into him, just to ensure that you, too, could benefit from optimal medical care, fruit of countless years and dollars of research. In hindu mythology, non-divine beings can undergo sex-change through the actions of the gods, as the result of curses or blessings or as the natural outcome of reincarnation. Unfortunately, modern medicine practitioners lack the transformative power of the Hindu Gods and must therefore use alternative methods, sometimes out of the disappointingly secular nature of science, to limit the loss inflicted by the trip they take from Mars to Venus.
How did “she” become a risk factor?
According to Maya Dusenbery, author of Doing Harm, medicine often has dangerous side effects on women because of what she refers to as the knowledge gap and the trust gap.
The knowledge gap refers to the lack of information about women-specific health risks, symptoms and response to medication – the result of decades of leaving women out of research. In fact, after the reported medical trial atrocities of World War II, the world became particularly skeptical towards the use of human subjects for research purposes, and women of bearing age had been banned from being used for clinical trial for (very legitimate) security and ethical concerns. These paternalistic measures also revealed themselves to be (perhaps falsely) cost-efficient: male physiology being relatively hormone-independent, it served as a consensus for the medical community and research methodology. This prohibition however led to poor knowledge of the effects of drugs on women. In 1980, when researchers conducted a major study to determine if taking low-dose aspirin could reduce heart attack risk, they enrolled 22,000 men and as little as zero woman. Perhaps it is worth to mention the fact that heart disease kills as many women as men. In fact, 80% of drugs the FDA removed from the market were sentenced to waste because of side effects on women (now imagine the waste in funds in research!). There have been changes since the NIH issued a guideline in 1994 for the study and evaluation of gender differences in clinical trials to ensure that the safety and efficacy of drugs would be adequately investigated in the full range of patients that would use the therapy. Unfortunately and unsurprisingly, this did not resolve the problem.
The knowledge gap also results from neglecting conditions that are more commonly or exclusively found in women. Such conditions, often of vague etiology such as chronic fatigue syndrome, fibromyalgia or endometriosis, are disproportionately under-studied compared to conditions that represent limits to men’s wellbeing to the same extent. These conditions being at the bottom of the health research agenda could let us believe that the very real suffering that affected women undergo simply does not represent enough of a research-funding incentive.
The trust gap refers to the observation that women’s voices are not taken seriously or are not given enough authority. In fact,women’s own reporting of symptoms (pain,fatigue…) are less considered than men’s. Women’s symptoms are more likely to be classified as psychologically- or psychosomatically- induced. Women are more referred to psychiatrists than men when reporting for the same symptoms. Women’s complaints are more likely to be considered exaggerated or assumed to be invalid. This psychologization of women’s health leads to a lack of trust in the female patient-physician relationship – leading women to report their symptoms less or differently, by fear of being labeled as hypochondriac or in need of psychiatric help. Gender bias in medicine can cause women to ignore symptoms, to be less proactive about their health management, to reach for alternative health care or to be redirected to trust-unworthy sources of information.
The two-view model
According to Ruiz and Verbrugge, gender-bias in medicine is due to assuming sameness or assuming differences.
Gender blindness is assuming sameness when there are genuine differences to consider in biology, disease, life conditions and experiences. In medicine, this comes down to extrapolating the results of the 70kg white male and assuming compatibility with female physiology. This hypothetical compatibility is deceitful; sex-based differences go beyond reproductive features. In fact, every cell of the body has a gender. Sex-based differences are particularly significant in liver metabolism, kidney function, hormonal influences, blood vessel sizes, stomach enzymes, RBC count, neural pathways and more. These differences alter the risk and disease profiles of women. This requires a switch of premises when addressing women’s health.
Added to these sex -based differences are gender-based differences of psychological or behavioural nature that find base in mostly-social construction of gender – diet, drinking habits, sexual behaviour, response to stress, use of illegal substances…
Assuming differences means exaggerating gender differences and stereotyped preconceptions about men and women. Some of these assumed, scientifically-unfounded differences are widely accepted within the medical community and are therefore transmitted intergenerationally via medical education. These medical myths can be debunked and their spreading can be halted, but other medical assumptions have shaped diagnostic infrastructures, which makes them more difficult to assess as gender-biased. Their well-established status perpetuates their questionable validity within the medical community.
More women fit the psychiatric disorder description perhaps because more women constituted the sample body of the very elaboration of the tools used to classify disorders (looking at you, DSM). This could have lead to more women being diagnosed with psychiatric conditions, more women being medicated, and it could have reinforced the belief that women are more likely to suffer from psychiatric ailments – a belief that reaches all the way to the other hospital wards.
There are other supposed reasons attributed to the gender-bias in medicine. Feminist critiques blame the gender order, the projection in society that women are less valued than men. Another possible reason is that the social subordination of women to men is mirrored by the medical research’s subordination of men-specific data to women’s physical conditions. Whichever the reason to fuel our frustration towards the situation, it is a reason linked to a lack of knowledge.
“So, is more knowledge the solution?” Well, our knowledge itself requires a critical approach; there is such a thing as “knowledge-mediated gender bias” – neglecting patients belonging to the sex in which a disease is known to be less common or severe. Regardless, knowledge about differences between men and women will not reduce the bias caused by gendered stereotypes or by unawareness of gendered discrimination associated with gender inequity. Such bias reflects dismissal of gendered attitude and faxing a few facts-to-read-during-lunch-break to the medical workforce alone will not change that.
A simple internet search about gender-bias in medicine will lead you to countless facts from researches realized around cardiovascular disease. CV disease is the triumphant textbook example of gender-bias in medicine. Perhaps because it affects men at a younger age, it is stereotypically (and erroneously) labeled as a male disease. The other half of the population (aka women) express the disease differently in symptoms (the textbook signs of chest pain is replaced with nausea, jaw pain, back pain – very different symptoms and less obviously assignable to a cardiovascular accident solely) and treatment response (aspirin as a preventative measure can be detrimental for women). Also, for men and women showing the same symptoms, the addition of “stress” as an indicative vignette created a significant gender gap in identifying the situation as of cardiovascular nature and women were more likely, again, to have it assigned as psychologically-induced. Attention has been brought to the issue and its potential fatal effects on women has reached the medical community and public. The difficulty to bring attention to a gender-bias in the diagnosis of a condition increases with the decrease of quantifiability of the condition. Conditions that are harder to quantify for various reasons – again, vague etiology, misdiagnosis, lack of awareness and research – are harder to asses and clincize and therefore less efficient at creating sublimatory headlines. Which of these would you think will receive the most visibility within the public: “7 conditions for which your doctor will let you die if you are a woman” or “the possible gender origin of the late recognition of fibromyalgia by the medical community”?
“Ok fine, we understand it is more complex than learning facts – then how do we limit our gender bias in medicine?”
It must start with research. An emphasis must be put on studies about the cognitive, behavioural and communicating processes creating gender bias. A greater sensitivity to sex and gender is needed in medical research, delivery and wider social policies is needed. More women must participate in research.
The American Heart Association credited recent gender-specific research with improving the diagnostic processes for non-obstructive coronary heart disease in women. “For decades, doctors used the male model of coronary heart disease testing to identify the disease in women, automatically focusing on the detection of obstructive coronary artery disease,” AHA cardiologist Jennifer H. Mieres explains. “As a result, symptomatic women who did not have classic obstructive coronary disease were not diagnosed with ischemic heart disease, and did not receive appropriate treatment, thereby increasing their risk for heart attack.”
It should be mentioned that there have been difficulties and resistance from the implementation attempts of a gender perspective in medicine. The existing conflicts between the various medical research approaches have contributed to this resistance. In fact, basic and applied biomedical research have higher status than gender research that adopts fundamentally differing paradigms. This hierarchy within the medical research is creating rational inconsistency through medically-related literature.
We need consciousness-rising activities and continuous reflections on gender attitudes among students, teachers, researcher and decision makers. Since the harm is based on unconscious (involuntary) bias, cultivating the physician’s critical capacity is crucial for the lessening of medical gender-bias.
As future medical practitioners, we must acquire the information on bias risks, be critical towards our assumptions, understand the source of stereotypes and cultivating the reflex of assessing situations as unique in themselves.
Further thought on the issue should be made in terms of intersectionality. Medical bias can also be age-, social class-, or race-based. What are the synergetic effects of medical bias on a person and population of persons belonging to an age,social class, race and gender that experiences disfavouring bias?
Some more legit people who have had a more scientific approach to addressing this issue:
Melinda Wenner Moyer, “Women aren’t properly represented in scientific studies,” Slate, (July 2010)
Lichtman et Al – “Symptom Recognition and Healthcare Experiences of Young Women with Acute Myocardial Infarction”, Yale School of Public Health, AHA Journals (2015)
Hamberg – “Gender Bias in Medicine”, Women’s Health Review (June 2008)
Doyal – “Sex, gender, and Health: The Need For a New Approach”, BMJ (November 2001)
Ruiz and Verbrugge – “A two Way View of Gender Bias in Medicine”, Journal of Epidemiology and Community Health (1997)
Holdcroft – “Gender Bias in Research: How does it affect evidence based medicine?”, Journal of the Royal Society of Medicine (January 2007)
Risberg et Al, “ A Theoretical Model for Analyzing Gender Bias in Medicine”, International Journal for Equity in Health (August 2009)
Alison M. Kim, Candace M. Tingen, and Teresa K. Woodruff, “Sex bias in trials and treatment must end,” Nature, (June 2010)
Maya Dusenbery, “Is Medicine’s Gender Bias Killing Young Women?” Pacific Standard, (March 2015)
Alison M. Kim, Candace M. Tingen, and Teresa K. Woodruff, “Putting gender on the agenda,” Nature (June 10, 2010)
 Vague etiology due to a lack of research
 Although alternative medicine may be the best solution for the patient’s ailments, it is often not covered by their healthcare plan and its necessity caused by a flaw of the national healthcare system would represent a health access inequality. Think of how being sick could affect a woman’s economical status and women’s already-existing economical vulnerability. Healthcare service neglect has serious side effects.
 In this Yale study, when no stress label was added to the classical heart attack symptoms, men and women diagnosis were the same. It is the “presence of stress” variable that was the catalyzer of the gendered difference in diagnosis.