Invisible women in medicine: How gender biases are affecting our health

In the 1980s, it was discovered that women with heart attacks died twice as often as men. Why? Because culturally the iconic symptom of heart attack has always been chest pain. But what few know is that this is a characteristic symptom in men; exhaustion, shortness of breath and nausea are more common in women, something that we and the medical staff themselves usually attribute to other causes such as anxiety or stress. If we have this lack of knowledge with heart attack, which is the leading cause of death for women in the world, how will it be with the rest of the diseases? In 2017, in a clinic in Santiago Oriente, a postpartum woman, despite having complained multiple times of pain and shortness of breath, was evaluated with an anxiety disorder and classified as an “emotionally unstable” patient, when what she had was a venous thrombosis that caused her death just 17 days after becoming a mother. In Chile, on the other hand, cerebrovascular attacks (CVA) are considered “a disease of men”, because the number of women who suffer from it is less. For the same reason, although cerebral thrombosis is on the rise in women and when it occurs it is more lethal for them, when they consult their symptoms they are associated with stress or anxiety. It happens in heart disease, it happens with different types of thrombosis and it happens in multiple diseases, from chronic pain to endometriosis: its symptoms are ignored or underestimated in women. According to the study Women’s access to health care: gaps that the future health reform in Chile must resolve, carried out by academics and researchers from the University of Chile, the Andrés Bello University and Medtronic, there are a series of very profound inequities in serious diseases, such as stroke, obesity, musculoskeletal pain, among many others. It is what is called “The yentl syndrome”, which defines the phenomenon where women receive erroneous diagnoses and treatments due to gender bias or because they do not conform to the most classic symptomatology, which starts from a male model. And that, sometimes, costs us our lives.

One of the researchers who has studied the subject the most is the Spanish doctor Carme Valls Llobet, author of multiple books on the subject, including Invisible women for medicine. In it, she focuses on the consequences of the lack of presence of women in scientific studies, where they have traditionally been excluded on the grounds that menstrual cycles and pregnancy make it a more complex study sample, that is: better we study men, which is easier, and we apply that body as a universal model. Even when rats or animals are tested they are only males; that is, many diseases or drugs have not been studied or tested in female anatomies. That finally ends up making us invisible in the practical exercise of medicine and therefore putting our health at risk. Chilean gynecologist Daniela Ribbeck, a member of the SOGIA and SOCHEG gynecological associations, agrees with this. “Since college we are used to studying male bodies for many more hours. Starting in first year in anatomy classes, did you know that no anatomy book includes the complete anatomy of the clitoris, but they do include the complete anatomy of the penis. A student once told me that he did not know how to listen to the heart in women, because they had always practiced with men’s breasts and he did not know how to do it with breasts. As most of the studies are in men, we know how to diagnose diseases in them very well. And there are times when the symptoms are similar in both sexes, but there are others when they are very different.

Daniela warns that women experience sex and gender bias -understanding the former as biological characteristics and the latter as assigned social roles- and that both have a negative impact on our health. “Regarding gender bias, we see that most scientific studies, especially drug studies, are done on male animals or on men. This, to eliminate the hormonal variables of the menstrual cycle when interpreting results. In this way, we have many drugs with effectiveness and safety studies in men but we do not know how they act in the female body”. Regarding gender bias, that is, those prejudices, preconceived ideas or discrimination that women receive in consultation, Daniela gives pain as an example, and how it is normalized more in women than in men. “Pain in women’s lives is assumed to be normal. So when a woman consults for pain during menstruation or pain during sexual intercourse, the health professional will most likely lower her profile, causing women to take up to 10 years to receive the diagnosis and treatment of diseases such as endometriosis or vaginismus”.

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A similar conclusion was reached by midwives Camila Rojas and María Begoña Carroza, who together with Daniela Paredes and Rony Lenz participated in the research on Women’s access to health care. “The prevalence of pain is higher in women and increases over 45 years. Likewise, chronic and/or persistent pain is more recurrent in women, with a third of them living with pain for periods of more than five years. While 60.7% of women have medical licenses associated with chronic pain, in men this percentage drops to 39.3. Even so, within our research, gender biases have been described in the medical treatment of pain in women compared to men: long waits to obtain diagnoses, less access to treatments and/or less effective ones, greater use of antidepressants and greater referrals to mental health professionals. And Carme Valss recognizes it in the same way in her books: “The doctor tells many women that they have nothing, that they are just nervous or they call them hysterical. In fact, women are prescribed five times more antidepressants than men and two times more anxiolytics. And they, who feel their discomfort but who respect medical opinion, end up believing that they are just nerves, when they are not. The chronic diseases that women suffer from the most are the least studied and the least compensated, therefore it is very easy that if the woman goes to the doctor tired and in pain it is attributed to nerve problems instead of looking for deficiencies what’s wrong with it. For example, with menstruation a woman should lose about 80 cubic centimeters of blood, but most lose more and go with a lack of iron for life, until menopause, which is a liberation. If this were taken into account more often in the consultation, many discomforts and pains with which women are forced to live would be avoided because they are not listened to enough”.

How to start reversing this reality?

When Daniela studied medicine 10 years ago, she did not have any class or teacher to reflect on any of these issues, but today, as part of the Chilean Gynecologist Association, she works for the incorporation of the gender approach in gynecological-obstetric care and teaches its students to be general practitioners who practice their profession with this perspective. “The gender approach, among other things, allows us to be aware of sex and gender biases in health, so we not only improve the quality of life of girls and women, but we can also save lives. There is still a lot of misinformation, most health professionals still do not understand what incorporating a gender perspective into our professional work means, but I have great faith that future generations will be different”

Likewise, Camila, María Begoña and the rest of the academic researchers are waiting for him; “There is international evidence that suggests how to incorporate the gender approach and perspective in health sciences education, however, it is something that as a country we are just working on and advancing, and it should be considered a generic-transversal competence in all the races. Only a few universities have incorporated gender into their respective educational models as a fundamental pillar in the training of professionals. It is necessary to discuss how Chile will allow a better approach to these gender gaps in the face of the constitutional discussion and health reform, and of course in the educational models of the training institutions, because there is an urgent need to improve and incorporate training on gender in health sciences education”.

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