Sexism in medicine: Why women are treated worse than men
MANY HEROINES RUBRICS "PERSONAL EXPERIENCE"shared stories of rare diseases, told how their complaints were not paid attention to for a long time: their illness was blamed on hormonal processes during the menstrual cycle, and some were advised to get pregnant and give birth as soon as possible in order to "improve their health". It is women’s complaints that doctors often do not take seriously - we understand how gender inequality affects our health.
For centuries, women's ailments were considered half-contrived, and feeling unwell was attributed to "hysteria" or "uterine rabies." It would seem that with the development of science such an attitude should have become a thing of the past, but even now many problems, "explained" by hormones or premenstrual syndrome, and even psychosomatics - without going too far into the question, of course. It seems that the woman is too sensitive being, taking everything close to her heart, which needs to “pull herself together” so as not to get sick. Hormonal oscillations, or painful menstruation, are suggested to be simply tolerated - “you are a woman.”
This attitude is the result of a lack of knowledge; women's health has not been practiced for a long time, and it has not been studied as well as man's. As a result, women are more likely to have conditions that modern medicine cannot explain: scientific evidence is simply not enough. Speech about such poorly studied processes, such as fibromyalgia and chronic fatigue syndrome - they are much more common in women, and historically no one wanted to invest effort and money in understanding their essence. Research decisions and funding were made mostly by men; as early as 1990, it was said that only 13% of the total research budget is devoted to studying the risks to women's health. "They finance what they themselves are afraid of," said Pat Schroeder from the US House of Representatives.
The difference in the study of male and female problems encourages confidence that women are characterized by hypochondria, and all the unpleasant symptoms - "in the head." Many of us went to doctors with complaints that did not reveal a clear physical reason - but at the same time, few people think that the doctors ’caution regarding patients and patients differs. Chronic fatigue can be the result of an autoimmune disease, but women are more likely to remain undiagnosed, because fatigue will be attributed to stress, lack of sleep and hormones. It is known that the diagnosis of autoimmune diseases takes an average of almost five years and requires visits to five doctors, with 75% of patients with these diseases being women.
In women who have applied for help with signs of heart failure, there is less chance of a complete examination - this phenomenon is called Yentl syndrome.
Studies show that gender inequality can be talked about not only in cases of rare diseases or conditions with blurred symptoms. Of the people who applied for emergency care with acute myocardial ischemia (developing heart attack), women under the age of fifty-five years were most likely to be mistakenly sent home. In 2015, a meta-analysis of 43 studies was conducted on the experience of women with heart disease - the publication was called “Does anyone see me? Does anyone hear me?”. Women noted that their symptoms were simply not treated as seriously as the complaints of men; some were denied necessary diagnostics (ECG or blood test for cholesterol), explaining that “such a young woman cannot have heart problems”.
Women who applied for help with signs of heart failure are less likely to have a full examination. This phenomenon is called Yentl Syndrome - after the heroine of the story, and then the film about a Jewish girl who dressed as a man to get an education. Interestingly, women who still had the necessary examination received the same intensive treatment as men - and this additionally underlines the essence of Yentl syndrome: in order to be treated properly, you need to show yourself as a man. By the way, it is in women that a heart attack is more often accompanied by manifestations that are not like the classic pain behind the sternum - such as stomach discomfort, nausea, and pain in the lower jaw.
Another important aspect is the attitude to health as something that a person creates by his way of life and for which he is responsible. It is easy to forget that avoiding stress (the most important risk factor for many diseases) is not always possible, and women are more prone to it simply because of how society works: how to recuperate when you do most of the housework, control the family logistics, you rest on the glass ceiling at work, and the world expects emotional service from you? The recommendation “to rest more” is difficult to implement, if the conditions do not imply the need for such rest for women. Responsibility for their health is good, but not everyone has the same opportunity to take care of themselves.
The authors of the meta-analysis mentioned above say that women with heart diseases faced with incomprehension and lack of support from their loved ones — and at the same time felt guilty for not being able to take care of others due to illness. “Mom can’t get sick, she should always be near” - these are the words of one of the patients of the study, where it turned out that women themselves often go to the doctor not immediately, but only after fulfilling all the “obligations” in relation to the family. Poor health is not just not enough to drop everything and relax or go to the doctor - women also hide it from their loved ones so as not to seem "hypochondriacs" or "whiners."
Yentl syndrome manifests itself in a variety of situations: for example, women are less likely to get good pain relief for abdominal pain. Brain tumors in women are diagnosed later than in men - and when they first visit the doctor, the symptoms of these most dangerous diseases are attributed to fatigue or even a desire to get attention. It is in women that doctors more often miss the signs of an impending stroke, and the diagnosis of lymphoma, cancer of the bladder, stomach, and other organs in patients takes a longer time than in men.
Another important problem is the study of how drugs work in the body of men and women. Until recently, few women were included in clinical studies; from 1977 to 1993, the FDA prohibited women of reproductive age from participating in studies of the early phases, where the safety of new drugs in healthy people is being studied. Considering that the time spent for participants in clinical trials of the first phase is paid, women were deprived of the opportunity to earn here; the prohibition was covered by paternalistic concern for “future offspring” - naturally, no one asked specific women who would like to participate if they planned to have children at all.
It is in women that doctors more often miss the signs of an impending stroke, and the diagnosis of lymphoma, cancer of the bladder, stomach and other organs in patients takes a longer time than in men.
Of course, in some measure it is simply more convenient to conduct studies of drugs in men: this is a more homogeneous population, without hormonal fluctuations, the menstrual cycle and the risk of becoming pregnant while taking a dangerous drug. But all this should only emphasize the need to study how drugs work in the female body, with all its features. Otherwise, we are faced with the fact that the next complaints will be written off to stress or fatigue - and they can only be the unintended effect of a drug that has not been studied on women.
In 1993, the US Congress obliged the National Institutes of Health (NIH) to include more women in their research. Nevertheless, as of 2015, the progress was still insufficient: the number of women in studies of the same cardiovascular diseases did not even allow them to draw up specific treatment recommendations. The 2010 publication noted that the percentage of women in studies of certain diseases is lower than the proportion of women with these diseases in the population: for example, in studies of hyperlipidemia or heart failure, 28 and 29% of participants were women, although in fact they share the incidence with men in half.
Moreover, if we talk about research conducted by government organizations (and here again we are talking about the US NIH), an imbalance is noted in the preclinical studies - those that are carried out on animals. The course of diseases such as multiple sclerosis (which is more common in women), it is crucial to study it on female animals. The choice in favor of male rats or mice is made due to the fact that females allegedly will not have stable indicators - after all, they have an estrous cycle (analogous to the women's menstrual cycle) and the associated fluctuations in hormone levels. In fact, this is not the case, and the results obtained in female mice vary no more than in males.
In commercial research, that is, conducted by pharmaceutical companies, they still strive to include more women so that the proportion of patients and patients with the disease being studied reflects their shares in real life. When studying completely new drugs, when the risks to the fetus and pregnancy are unknown, women are simply asked to use highly effective contraceptives — and before that, the situation looked as though no one could regulate their ability to become pregnant. If we are talking about a substance that can penetrate sperm, then the requirements for contraception are imposed on male participants. Efforts are being made to ensure that the participants include people of different ethnic origins, and older people, because the metabolism of drugs may depend on these factors. After taking the same dose of the drug, its concentration in the blood may suddenly be different in people of different sex or origin. Of course, it is safer to study a medicine that older people will take in young people and with relatively stable health - but this is hardly advisable.
Questions of gender inequality in medicine began to be raised by feminists almost fifty years ago - then they first spoke that women's complaints, even if they did not differ from men's, were more often labeled as psychosomatic. Practically everyone is now aware of the problem: regulatory organizations are trying to track and encourage women's participation in clinical studies, and significant grants are allocated to study the biological differences between the sexes. European experts advise researchers to change their attitude towards women, considering them not as a “subgroup”, but as half of the population.
Now we are talking about the fact that research should be open to pregnant women and nursing. Treatment of HIV infection or diabetes mellitus during pregnancy is necessary, and therefore it should be studied in such conditions.
The FDA has opened for everyone to access information about who exactly participated in the research of new drugs, registered since 2014. Back in 2005, the European Medicines Agency issued a report, which stated that there was a fairly good representation of women in research and that it was time to start taking into account not only gender, but also gender. Now in Europe we are talking about the fact that research should be open to pregnant and lactating women - in certain situations, this cannot be done. Treatment of HIV infection or diabetes mellitus during pregnancy is necessary, and therefore it should be studied in such conditions. By 2020, in the European Union, more than 80 billion euros will be invested in the project of Horizon 2020, dedicated to gender integration - not only in matters of health and medicine.
Activists raise issues of medical sexism in public: Katie Ernst, who was not diagnosed with an autoimmune disease for a long time (Sjögren's syndrome), wrote off complaints about depression or hypochondria and created the blog MissTreated, which collects stories of women who feel gender inequality in diagnosis and treatment on myself. In March 2018, Maii Dasenbury’s book “Harmful” was published, dedicated to how women’s complaints are chronically ignored, misdiagnosis made to them and incorrectly treated. I want to believe that in the coming decades a lot will be done to achieve real gender equality in medicine too.
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