Why medicine still has a women’s problem. And what we can do about it
A few years ago, I stormed into the local emergency room with all the symptoms of food poisoning. Livid and nauseous, I immediately got upgraded to the front of the queue; within minutes, a physician was prodding, palpating, questioning, and surmising before concluding:
“Your case is puzzling. You have all the symptoms of food poisoning but one. So I’m just not sure. Are you positive that you’re not having your period?”
In between bouts of nausea, I had reassured him twice that I was not on my period. And that, having had it for almost two decades by that time, I could tell the difference between menstruation and food poisoning. I didn’t know any woman who couldn’t. But I had encountered a male doctor who couldn’t disentangle gender from clinical symptoms.
As recently as a century ago, a physician in his position may have identified my “wandering womb” as the triggering factor for my symptoms. He wouldn’t have been the first male doctor to struggle with the female anatomy. As Caroline Criado Perez writes in Invisible Women. Exposing Data Bias in a World Designed for Men, “(…) the ancient Greeks (..) kicked off the trend of seeing the female body as a ‘mutilated male’ body. The female was the male ‘turned inside in’. Ovaries were female testicles (..) and the uterus was the female scrotum (..). The male body was an ideal women failed to live up to.”
Women are still their gender first and their biology second as they navigate medical systems and doctors’ mental geographies. They cannot be trusted to speak about their bodies truthfully. Embellishment is presumed until disproven; pain believed to be a mental health issue and not a physical one; and most concerns dismissed as products of feminine hypochondria. No wonder a growing number of women distrust medicine and swell the number of “measles moms.”
But how did we get here?
And it starts early — with research and teaching on health. Despite differences in men and women down to cellular levels, scientists routinely exclude or under-recruit female subjects — either human or animal — for clinical trials, even for diseases that tend to affect more women than men. Take heart disease. As Amy Westervelt writes in The Guardian, “cardiovascular disease is the number one killer of US women, and it affects men and women differently at every level. But only one third of cardiovascular clinical trial subjects are female and only 31% of clinical trials that include women report results by sex.” Similar trends occur in the study of anxiety, depression, dementia and lung cancer, all conditions affecting women in high proportions and whose evolution is influenced by changes in hormones and by sex differences.
Not even physical suffering shields women from discrimination; pain, as it turns out, is not an equal opportunity assailant. As Diane E. Hoffman and Anita J. Tarzian stated in their seminal paper The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain: “Women are more likely to seek treatment for chronic pain, but are also more likely to be inadequately treated by health-care providers, who, at least initially, discount women’s verbal pain reports.”
Talking about pain, endometriosis is estimated to affect one in 10 women. Yet, it takes an average of eight years for women to receive a diagnosis; much of that time is spent hearing “It’s all in your head, dear” or “Come back when you’re ready to have children.” Did I hear anyone say “wondering womb” again?
Even when women do get diagnosed, receiving the right treatment in the right doses is anything but straightforward. Medication has different effects on men and women, because of differences in “average body size, hormones, metabolism, and fat distribution.” But, considering the dearth of toxicology studies accounting for sex differences, women may be given inappropriate doses of medication (either higher or lower than what they need).
If you think all these examples are bad enough, it gets worse. Women of colour are more likely to experience adverse health outcomes, e.g., to die in childbirth or to die from breast cancer, than white women.
Therefore, Malika Sharma surprises no one when she writes in The Lancet’s theme issue on Advancing Women in Science, Medicine and Global Health, that “historical gendering of medicine prioritises particular types of knowledge (and ways of producing that knowledge), and creates barriers for critical, and specifically feminist, research and practice. Patriarchy has ripple effects, such as harassment, the gender wage gap, and gender segregation in specialties and medical leadership.”
Reluctantly, the doctor prescribed the treatment I needed to get off the food poisoning rollercoaster. But, as I clutched my stomach, something viler than nausea lingered in my gut: he thought me a delicate, menstruating flower. As if that would have been pain-free either.
There are systemic barriers to women’s access to healthcare, prevention programs, accurate diagnosis and treatment. It’s not about the “bad” doctors but about medical cultures embedded in societal norms, values and beliefs. As Criado Perez adds, “(…) the representation of the male body as the human body persists. A 2008 analysis of a range of textbooks recommended by twenty of the ‘most prestigious universities in Europe, the United States and Canada’ revealed that across 16,329 images, male bodies were used three times as often as female bodies to illustrate ‘neutral body parts’. (..) The gender data gaps found in medical textbooks are also present in your typical medical-school curriculum.”
As women, we must continue to fight for our bodies, pain and symptoms to be taken seriously and without prejudice.
There are things we can do, individually and collectively. Remember Dr. Tia Powell? She advises women to stand their ground with medical professionals when they feel their health concerns are not being taken seriously. One way to do that is to ask doctors whether the treatment prescribed, or lack therefore, is in line with clinical guidelines. Another is to “be direct [and say something along the lines of] ‘I’m concerned, and I feel that maybe you aren’t hearing me. Help me understand why you don’t see this as a problem.’”
Collectively, we can advocate for and support more women in science and health. Globally, women make up less than 30% of scientists but represent 75% of the health workforce. However, as Geordan Shannon and her colleagues write in The Lancet, “imbalances in specialist training participation persist, with women remaining the minority in surgical specialties (..)” and “(..) holding a small fraction of leadership positions.”
We need more women, of all races and backgrounds, in medicine. But that’s only half the battle. It’s high time we recognized that medicine does not operate in a cultural vacuum; and that medical professionals are still struggling to separate the stereotypical women from the flesh-and-blood women. We need to streamline sex and gender in the practice of medicine and in the understanding of women’s health across the continuum of care (from prevention to treatment). Research needs to include men and women alike — as scientists and clinical trial subjects — and medical education to catch-up with women’s complex health needs. Settling for less means condemning women to pain, humiliation and preventable deaths. And their families to loss, financial ruin and emotional devastation.