Any time you walk into a doctor’s office and fill out a medical history form, there’s a good chance it will ask for both your gender identity and your biological sex. There’s a reason for that: Sex and gender can have an enormous impact on health, affecting everything from heart rate to proper dosages for medications.
To some extent, the public is aware that a patient’s biological sex can influence conditions they are diagnosed with. Women tend to suffer higher rates of autoimmune disorders, for example. Gender — which encompasses cultural roles and expectations — can also impact health outcomes in ways that sex does not. The coal industry, for instance, is overwhelmingly male-dominated, meaning that most of the workers who are exposed to coal dust and consequently develop black lung are men. What we are slower to recognize, however, is how biological sex can influence not only what conditions are likely to present in a patient, but how they present.
Women experiencing a heart attack, for instance, may not have the crushing chest pain that men do. Their blood pressure readings might be dangerously elevated, placing women at higher risk for heart disease, even if still falling in what doctors often consider to be a normal range. Their artery blockages may not appear on angiograms or other routine diagnostic tests. The symptoms they might experience during heart attacks, such as nausea, fatigue, and abdominal pain, can be more easily mistaken for different ailments. And, studies find, if faced with doctors who aren’t trained to recognize heart attack symptoms as they present in women, they are much more likely to be misdiagnosed and sent home, with potentially fatal consequences.
Our understanding of women’s health has changed drastically over the past few decades. For much of modern medicine’s history, experts say, doctors largely followed a philosophy of “bikini medicine,” which theorized that men and women were medically interchangeable save for the parts of a woman’s anatomy that could be covered by a bikini. This, coupled with the paradoxical belief that men were easier to study, meant that women were routinely excluded from medical research, and, consequently, from the understanding of the various ways diseases present in people.
This problem extends to mental health as well. Girls and women with attention-deficit hyperactivity disorder also tend to display different symptoms than their male counterparts. According to one study, girls with ADHD are less likely to exhibit the impulsivity and hyperactivity that is common among boys with ADHD, and are more likely to experience emotional problems such as depression and anxiety. It also takes more clinic visits on average before girls receive ADHD diagnoses, and they tend to be older than boys when they are finally diagnosed.
It’s easy to think of these disparities as the result of individual instances of sexism from medical providers, and that can sometimes be the case — there are plenty of studies that show that women are more likely to be disbelieved, dismissed, and under-treated when they present with symptoms — but the problem’s roots are more systemic. If we want to reduce disparities in health outcomes between men and women, we need to rethink our understanding of these medical conditions and their diagnostic criteria — and that starts in the classroom.
Carolyn M. Mazure, the director of Women’s Health Research at Yale, founded the center in 1998 to address what she calls the “knowledge gap” in our understanding of women’s health. Back then, Mazure says, the term “women’s health” was more or less synonymous with obstetrics and gynecology, erasing the impact of sex and gender in all other aspects of medicine. When medical research did include women, it generally combined them with a group of predominantly male participants, making sex-specific data about a disease’s prevalence, symptoms, and treatment challenging to track down.
“The tradition within science was really to pool the data, homogenize the data, rather than separate out the data on the basis of sex or gender,” Mazure says. The lack of sex-specific analysis meant information about women’s health was rarely considered in medical decision-making.
The scientific community has gradually begun to reevaluate such practices, which, Mazure points out, is exactly what ought to happen. Science is “supposed to evolve, it’s supposed to change,” she says. “And the way in which it seemed to me we needed to make changes was to start with people who were being taught how to be physicians.”
In addition to funding research that focuses on women’s health throughout all areas of medicine, Mazure’s center is working to update Yale School of Medicine’s curriculum for future generations of doctors. A 2019 study analyzing Yale’s medical curriculum found that less than a quarter of lectures and workshops for first- and second-year students mentioned the impact of sex and gender, and only about 8 percent explored the issue in depth, a problem that Mazure says plagues medical schools around the world. Today, she and her team are working to incorporate sex- and gender-specific information into all aspects of medical training.
“We don’t want to separate out the health of women and discussions of how sex and gender may influence health outcomes, we want to integrate it into everything,” Mazure says. “There’s so much [data] now to support the fact that in many areas, women are not getting sufficient attention in terms of their medical needs because the data haven’t been integrated into education.”
Part of that integration includes updating the terminology doctors use to describe women’s symptoms, especially when they don’t fit the traditional diagnostic mold. The term “atypical,” often used to describe symptoms of a disease as they appear in women, “implies strongly that there is a typical way, and that’s the male way,” Mazure says. “You can no longer set norms based entirely on male data, because for many things, those norms are different.”
Updated information about the role of sex and gender in medicine shouldn’t be restricted to medical schools, either. Referrals for ADHD evaluation, for instance, often come from a child’s teacher. The faster we are able to identify and treat medical issues, the fewer people will have to suffer in medical limbo, unable to receive adequate treatment.
Turning a blind eye to women’s health only creates more barriers for people of all genders fighting for medical care. We need to update our collective understanding of the numerous ways that sex and gender impact our health in order to end medical disparities between men and women. Rewriting the diagnostic criteria is about more than just political correctness — it will actually save lives.
Maya Homan is a co-op at the Globe and a journalism student at Northeastern University. Follow her on Twitter @MayaHoman. Send comments to firstname.lastname@example.org.