Dr Elizabeth Blackwell paved the way for female clinicians when she became the first woman to receive a medical degree in the United States. Blackwell's motivation to pursue medicine came from a dying close friend, who said that her suffering would have been lessened had her doctor been a woman. In her training, Blackwell was ostracized by teachers and patients alike, but she persevered and in 1849 became the first female Doctor of Medicine in the United States. Before this – and for some time after – women were excluded both in medicine and broader science. As a result, much of our early understanding of medicine, anatomy, and disease was formed by male physicians with male bodies in mind.
A person’s sex is usually determined by an XX or XY pair of sex chromosomes. The physiological profile that these combinations give rise to sometimes means that one sex may present with different symptoms or conditions to the other. A recent paper published in Endocrine Review discusses why these sex differences matter when it comes to the innovation of drug therapies.
"When we understand the ways sex differences operate at baseline in health, which can either worsen the course of a disease to amplify differences in health outcomes, or protect against it, we can more effectively prevent and treat medical conditions," said Dr Aditi Bhargava of the University of California in a statement. "Without exploring sex differences, some drug candidates that could be beneficial to women never have the chance to make it to market. The process of developing drugs using only males of a species in pre-clinical studies likely contributes to the higher rates of adverse drug reactions in women compared to men, failure to see efficacy in clinical trials, and translation to therapeutics."
We have seen the negative effects of male bias in medicine in the example of the common symptoms of a heart attack which – though more common in males compared to females of the same age – affect both sexes, but present with different symptoms. Research presented at ESC Acute CardioVascular Care 2021 found that chest pain is misdiagnosed in women more frequently than in men, with an initial diagnosis of acute coronary syndrome being considered less likely in women even when they have contributing genetic factors.
“Our findings suggest a gender gap in the first evaluation of chest pain, with the likelihood of heart attack being underestimated in women,” said study author Dr. Gemma Martinez-Nadal of the Hospital Clinic of Barcelona, Spain, in a statement. “The low suspicion of heart attack occurs in both women themselves and in physicians, leading to higher risks of late diagnosis and misdiagnosis."
A further contributor to the mystery and mistrust surrounding “women’s issues” is a historical tendency to plug gaps in the diagnosis with hysteria narratives. The word “hysteria” comes from the Latin hystericus (meaning "of the womb") to describe a woman’s insanity that’s triggered by some dysfunction of the uterus. It no longer carries such an association with female reproductive organs, but can still be wielded as a silencer for female patients with “no medical explanation” for their pain. It suggests that a “mysterious” or as-of-yet undiagnosed illness is the result of an exaggerated and untrustworthy presentation rather than a physical illness.
An excerpt from Pain and Prejudice by Gabrielle Jackson recently published in the Guardian highlights that it’s a problematic approach that regularly emerges in the experiences of women with symptoms that persist after treatment. One such example featured in a TikTok video which recently went viral by actor, singer, and photographer Amanda Lee (Who recently featured in Dr Joshua Wolrich's podcast Willing to be Wrong which tackles weight stigma in medicine). In the video, she shares her experience trying to seek treatment for ongoing stomach cramps after several doctors had been unable to diagnose the source. Finally speaking with a gastrointestinal doctor, she expressed her condition was preventing her from eating only to be told “maybe that’s not such a bad thing.” A later appointment with a different clinician led to appropriate investigations that unfortunately confirmed she actually had colon cancer.
The traumatic tale is unfortunately as devastating as it is familiar, demonstrating how societal norms have worked their way into the diagnostic process. While it’s true that “common things are common and rare things are rare,” (with colon cancer being a rare cause of stomach pain) the interaction demonstrates the obstructive bias that too often features in the diagnosis and treatment of female patients.
A study published in Feminism & Psychology looked at the language commonly used by clinicians treating patients for endometriosis, a painful condition where tissue similar to the lining of the womb grows elsewhere in the body. A telling quote from one clinician features in the paper’s headline, “Do mad people get endo or does endo make you mad?” (As if this study rating endometriosis patients' attractiveness wasn't bad enough...)
“The historical hysteria discourse was most often endorsed when discussing ‘difficult’ women, referring to those for whom treatment was not helpful or who held a perception of their disease alternative to their clinician,” write the authors in the study. “Rather than acknowledge the limitations of medical knowledge, medicine expected women to take control (with their minds) of their disease (in their body) by accepting their illness, making ‘lifestyle’ changes, and conforming to their gendered social roles of wife and mother.”
This is of course not to say that all practicing medical staff are guilty of male bias, only that some of the fundamentals underpinning the diagnosis and treatment of certain conditions may need tweaking to establish their suitability for all sexes. Growing research is evidence of the need to eliminate problematic narratives from patient care to abolish outdated knowledge which no longer carries any clinical value.