Written By: Caroline Bussu
Edited By: Aishwarya Murthy
Design & Illustrations By: Mahika Khandelwal
Shortness of breath, nausea, vomiting and back or jaw pain. These are common heart attack symptoms in women. Unfortunately for women, these symptoms do not align with the ‘standard’ or ‘textbook’ symptoms associated with heart attacks by doctors. Consequently, women are 50% more likely to be misdiagnosed when having a heart attack, which increases the likelihood of that heart attack being fatal by 70%.
This is one of the many examples of how gender bias in healthcare directly affects women and their ability to receive equal care compared to their male counterparts. In order to fully understand such a tragic statistic, it is important to take a step back and consider how we got there in the first place.
Science made by men for men
The trust we have in our healthcare systems relies upon the decades upon decades of scientific research that back up modern medicine with evidence. We like to believe scientific research to be objective, which is what allows it to be so effective.
The history of women in scientific research proves to be contrary to such a belief. It was only in 1994 that the American National Institute of Health (NIH) issued its guideline for clinical trials to include measures that ensured the safety and efficacy of drugs for both men and women. Meaning that in large part, the scientific evidence our healthcare systems are based on has simply not included women until recent years. As a result, we quite literally know less about women’s biology, pathology and effectiveness of treatments.
There are various reasons researchers have used to justify the exclusion of women in clinical trials. The first one being concerns surrounding the potential detrimental effects that a trial could have on women’s ability to carry healthy children in the future. Although such concern may appear well-intended, it fails to differentiate women by age, gender or sexual orientation or wish to bear children.
Most of all, it ignores the fact that women are able to make their own decisions. Not only is the justification incredibly paternalistic but it also reinforces a dangerous notion that men and women only differ in terms of their reproductive organs.
The assumption then is as follows: there is no need to unnecessarily endanger women by including them in scientific studies since we can simply take men’s data and extrapolate it to women.
Another prevalent reason given by researchers to justify the exclusion of women in trials is that women’s menstrual cycle has confounding effects on results. The different hormone levels lead to higher variability of results. The only way to counter that is to have a larger sample, which increases the costs of the trial. Therefore, researchers opt to exclude women as it is cheaper, simply be extrapolating to women later on. It is enough to take a look into the statistics on the US drug market to see just how wrong this assumption is, where 8 out of 10 drugs taken out of circulation between 1997 and 2000 were due to adverse side effects in women alone. The reality is that we are left with a healthcare system made by men for men.
Although clear improvements in regards to women’s equality in scientific research have been made in past decades, women continue to suffer from the consequences of a historically biased system.
One incentive governments could provide to push scientific research to become more gender-equal, is to ensure that their grants cover the costs of a truly representative study. The increased variability of results of such a study almost quadruple the costs. Therefore, researchers must be adequately financially supported in order to achieve gender equality in research. It is also in the interest of pharmaceutical companies to have representative studies of their drugs, to avoid the costs of later on pulling their drugs from the market due to adverse effects.
Teaching the template
The assumption that the male-dominated evidence gathered through ‘objective’ scientific research can be equally applied to women, is further perpetuated by medical curricula. Indicating that future doctors are taught a template of what health or sickness looks like that is in reality only accurate for half of the world’s population. Women’s symptoms are instead described as deviant or anomalies to the so-called norm. This increases the chances of women being misdiagnosed, or undiagnosed at all because they do not fit into any of the boxes.
It is important to note that this gender bias goes both ways. Due to the stronger societal association between women and mental health issues, especially for issues such as depression or anxiety, the evidence in the field is largely female-dominated.
Consequently, when men are compared to the depression template they often go mis- or undiagnosed.
One explanation is that men often mask their depression through alcoholism, substance abuse or other risk-taking behaviour. Another explanation is that due to the constructs of masculinity, men are less likely to communicate when they are in physical or mental pain. They want to maintain a stoic image of themselves even at the expense of their own well-being. Thus, making it harder for doctors to diagnose them with illnesses such as depression. Some researchers have even argued that the misdiagnosis of depression in men is a partial explanation as to why men make up 75% of suicides even though women are twice as likely to be diagnosed with depression.
A more gender-aware medical curriculum would encourage medical students to keep in mind the limitations of the evidence they will base their diagnosis and treatment on. Therefore, it is necessary to move away from relying on one-sided ‘templates’ and shift towards understanding that symptoms might be displayed or communicated differently across genders. In order to achieve such a gender-aware curriculum, the active efforts of professors is required. Unfortunately, research has found that male medical teachers assessed gender as less important in professional relationships than female medical teachers. It will require a change of mindset to realise a more gender-aware medical curriculum and consequently more gender-aware doctors.
However, there are examples of medical schools which have attempted to incorporate a more critical approach to the content they teach their students. In Malaysia, the prime medical schools of the country discuss how a patient’s context such as the family, community and society influence their experience of health and disease. Thus, teaching students to look beyond the templates given by scientific research, and personalise each diagnosis and treatment to every single patient. Nonetheless, what is still largely missing in universities across the world is the inclusion of specific courses on women’s health that could work to counter the biases coming from traditional medical education.
In fact, even though male physicians may assess gender as less important in their relationships with patients, research shows that their gender does in fact have real consequences for their patients.
For instance, female heart attack patients have higher mortality rates when they are treated by male doctors versus female doctors. The same study also found that male physicians who worked with more female colleagues and had treated more female patients were more efficient in treated female patients. Proving two things — first that the consequences of gender biases can be mitigated, and second that once again women have to bear much of the burden of gender bias. The fact of the matter is that the chances of any patient’s survival should never have relied upon the gender of their doctor in the first place.
Even considering the solution to have a diverse healthcare workforce to ensure equal patient care is difficult to guarantee. Still today, the majority of doctors are male while the majority of nurses are female.
In Singapore, for example, up until 2002 there was a quota in place to ensure that no more than one-third of medical students were female. It was argued that female doctors left the workforce too soon or only worked part-time, and so were too costly for the system and simply not worth the cost. Although this quota was lifted, the Singaporean healthcare workforce is still not equal across the genders, since family-friendly work arrangements are still lacking. Once again, instead of looking at the system and identifying the problem, the burden is carried by women.
The reality of gender bias in healthcare becomes increasingly grimmer when a more intersectional perspective is adopted.
African American, Native American and Alaskan American women, for example, are three times more likely to die due to pregnancy complications compared to white women.
This can be explained by the fact that an African American woman has two biases working against her. First, that of being a ‘hysterical’ woman who should not be taken as seriously as a man when voicing any pains or concerns regarding her health. Secondly, that of being an African American individual who due to racist beliefs is thought to be able to endure more than their white counterpart. Therefore, doctors’ unconscious biases will lead them to overlook signs of potential complications, as well as dismiss any valuable concerns communicated to them by their patient.
Although the intersection between race and gender is probably one of the most documented in healthcare research, there are various other intersections at play. For example, gender and sexual orientation, where women who are part of the LGBTQ+ community are at higher risk of sexually transmitted diseases due to the misinformation around same-sex transmission. Lesbian and bisexual women are also ten times less likely to have had a cervical screening in the past three years than straight women, with almost 40% stating they had been told they did not require the screening due to their sexual preferences.
The intersections in the quality of healthcare for women are numerous, and there is no single solution that can fix them all. But bringing awareness to these issues is a start.
Light at the end of the tunnel
All too often, on all levels, conversations about women’s health are still focused on reproductive health alone or in the context of their roles as caregivers. This only reinforces stereotypes that already exist, and distracts from the reality that women’s health differs from men’s in more aspects than one. Not knowing or accepting these differences, promotes a healthcare workforce that directly hurts female patients.
However, while it can be difficult to appreciate the real progress that has been made in regards to gender bias in our healthcare systems, it does not mean that it does not exist. The statistics shared in this blog post alone, are incredibly devastating and infuriating. However, the truth is that we are moving in the right direction. Take countries such as Latvia or Estonia for example, where women make up 74% of physicians. Similarly, although on average only 30% of researchers are women, in countries such as Myanmar this number skyrockets to 75% or 55% in Tunisia.