Medical Controversy: Gender Bias in Medicine

Yup. You read it right. I'm going to cover gender bias in medicine. Don't worry about me I'm wearing my asbestos outfit. Even so... hang on. This is not going to be a short post and it may occasionally sound like a rant.

Before I begin I'll start with a disclaimer. I have an unavoidable bias on this topic. You see I'm male. I thought I'd better get that out of the way before I start. Full disclosure is important after all.

In case you think this will just be a review of the literature... you're only partially right. I'll also explain my view on gender-bias in medicine and list for you what I wish could happen to further the discussion in a sane and sensible manner. So let me give you my position on gender-bias in medicine before I get into the thick of things.

To the question "Is there gender bias in medicine?" my answer is "No and Yes - in that order". And that's a firm answer which isn't at all indecisive. Don't believe me? I'll explain later.

I've worked my entire career in healthcare. First in hospital computer departments and now for a regional digital imaging repository. I'm not a clinician nor do I have any medical training. I work with computers, systems, software, and users. Even though I have no formal medical training there have been occasions over time where people start telling me their theories about healthcare and medicine as soon as they learn I work in healthcare.

One topic that bubbles to the surface every once in a while is how the medical community isn't serving the best interests of women and gives preferencial and better treatment to men. When the topic would get raised I had a decision to make.

You see if the conversation was about specifics and based on some new study I didn't mind participating at all. If someone just wanted to make a small point or just make small talk I'd be nice and polite. When the blanket accusations and sweeping statements started appearing I had to decide how polite to be.

Should I be quiet and nod quietly? Bite my tongue? Politely ask questions to find out how much the other person actually knows about the subject? Or start asking pointed questions and bring out the heavy guns of evidence to shoot down an endlessly repeated list of baseless and disproven claims?

Let me be clear. I don't believe that all claims of bias are baseless or without merit. What would get me going is when a person would go from "I read in the paper that..." to "...and that's why women are suffering and not getting adequate care..." to "...women are still treated like second class citizens." all in one breath.

 This was usually followed by one or more of these:

• women are underrepresented in medical studies
• women were (or are) not allowed in clinical drug trials
• men are getting more surgical procedures than women
• men get more medical care than women
• women get fewer diagnostic tests and procedures than men
• medical technology is developed for men first

All these are vague accusations that people, men and women, make against medicine and medical research. I've pushed a few people over the years and asked how they know these things and what convinces them that they're true. One person in particular tried to make me feel inadequate and stupid since I didn't just 'know' that this is the way the world is. Apparently having coherent arguments to back up one's claims wasn't that important. He felt that if I didn't agree with him that there was a problem then I was a perfect example of how the medical community looks at women.

Did I mention I'm not part of the medical community?

Plus trying to make me feel inadequate because I didn't 'know' these truths didn't work. Usually I tried to be somewhat polite but I did push back quite hard in that particular case.

It's not just the general wisdom that tells us repeatedly that women are not being treated as well as they can be by the medical establishment. Just recently there were three op-eds in the journal Nature that were summarized in a press release that made the rounds. One place the press release landed was at The Institute for Women's Health Research at Northwestern University. Dramatic reading for a press release. Nature magazine wants you to log in or pay to read the op-eds... so for most of us the press release is all we're going to get. Give it a read. It won't take long. It's just a press release.

The Nature op-eds aside I've noticed that the trend seems to be changing. There are less outright claims of sweeping bias in the media. The press coverage tends to be very specific now. If there is a study that shows some bias against women then it gets written about. The article is filled with the usual "it may be a subconscious bias but it still exists" type of wording. There is usually a subtle underlying assumption that this is just more of the same and shouldn't come as too much of a surprise. Often there is some wording to the that says "this just shows how much progress still needs to be made". The articles start specific but then subtly reinforce the notion that there is a large underlying problem.

Notice that we don't seem to hear about studies that show a lack of bias against women. Who's going to read those? If someone finds that women are treated as well as possible will I read it in the paper?

An example of this type of article comes from closer to home than the journal Nature. The Globe and Mail has a perfect recent example with Men twice as likely to get knee surgery. It's an article that covers research on gender bias. The research was based on checking on only 29 orthopedic surgeons and 38 family doctors (of which only 12 were women) by sending fake patients of both genders and seeing if knee surgery was recommended. A small study with a small sample size gets a write up in the Life section of the Globe and Mail. I'd be much more interested if and when there is a bigger and more controlled follow up study myself.

On those few occasions where I started to take people to task and ask them how they 'knew' women were not being treated well in medicine I had an ace up my sleeve. I had counter arguments and challenges because of an article that appeared in the Atlantic magazine back in the summer of 1994. The Sex-Bias Myth in Medicine by Dr. Andrew G. Kadar took me by surprise when I first read it.

If you had asked me about sex-bias before I read Dr. Kadar's article I would have blindly agreed with the common wisdom. Of course women are mistreated by modern medicine. It's simple and obvious. Everyone says they are mistreated so it has to be. Right?

Wrong. Potentially very wrong. Don't believe me? Go read Dr. Kadar's article. Go on. I'll wait.

Dr. Kadar made me think about the assumption that women are short changed by the medical community. He did so by first presenting the accusations and the prevailing common wisdom. Taken as a whole they are damning. To quote Dr. Kadar:

Discrimination on such a large scale cries out for restitution--if the charges are true.

He then looks at each accusation and they are all found wanting. From discrimination in the number of diagnostic tests, to the number of referrals for bypass surgery, to the question of women in heart disease research, to whole new surgical techniques that were developed for women first, to the development of ultrasound imaging originally for women, to the amount of research funding spent specifically on each gender. For each Dr. Kadar slowly builds the case that women are doing quite well and that the bias either isn't there, has other legitimate explanations when you get past the initial apparent bias in the numbers, or is against men and not women.

When it comes to research dollars the apples-to-oranges comparison he makes is between breast cancer and prostate cancer research. This is a particular chestnut used by people arguing against gender-bias against women and this is one case where I'm not sure I agree with the premise.

The premise is that breast cancer predominately afflicts women and prostate cancer occurs in men. The number of deaths are similar but not the amount of money spent on research. Much more money is spent on breast cancer research. Therefore there is an inequality or bias against men. At least that's the premise.

I'll be honest on this one. I'm not going to take this argument at face value. Breast cancer and prostate cancer are different. I don't know enough about when in a person's life breast cancer and prostate cancer occur. I don't know enough about whether breast cancer and its treatments make a bigger difference to quality of life than prostate cancer and its treatments do. I don't know if more money should be spent on one or the other. I do know however that at first glance the disparity in research funding seems quite disgraceful. As do many of the facts and figures presented by those arguing that there is a bias against women. At first glance the numbers can look damning. With some investigation the numbers may be much less damning. They may even signs of bias the other way.

As I said I'm not sure on what the correct view of the breast cancer vs prostate cancer research funding discrepancy should be. I don't know if breast and prostate cancer should have similar research funding levels. That's one of the problems with the blanket arguments that women are not being well served by medicine. There are usually more factors at work and other explanations to think about. Statistics without background are meaningless.

When it comes to women in clinical drug trials it turns out that women weren't excluded from drug trials completely. Drug trials go through 3 phases. Women with "childbearing potential" were excluded from phase 1 studies and early phase 2 studies. The reason for these exclusions in the early stages? The early stages when drugs are being tested to see if they are at all safe and not just effective for their intended use? The reason was the thalidomide tragedy of the 60s. Even so the exclusion was removed in 1993, a full year before the article was written.

Do you believe that women were completely excluded from all clinical drug trials in the U.S.? And do you think the ban is still in place? That's the common wisdom that people keep mentioning. It amazes me that people still talk about the exclusion as if it was total and as if it is still in effect.

Dr. Kadar then makes a point I hadn't seen made before. One I didn't grasp until he pointed it out. For all my life I've lived under the assumption that women naturally live longer than men. In my lifetime they always have. Historically though that wasn't the case. Women lived shorter lives than men until this century.

And yes... much of that newfound lead in life expectancy is due to better care during pregnancy and childbirth. Which is, by any definition, medical care at its finest. 

But if you look at the numbers you'll see something else. It took me a while but over time I noticed it. In 1920 men lived to 53.6 and women to 54.6 years old. In 1990 men lived to 71.8 and women to 78.8 years old. Women lived a year longer than men in 1920 and 7 years longer in 1990. But did you catch the other bit of data in those numbers?

Both men and women live longer in 1990. Men have added 18 years to their lifespan and women have added 24 years. Men and women have both benefited from better healthcare, antibiotics, curing of diseases, and advances in medical technology. I think we forget how well we all have done thanks to medical research and technology.

In a nutshell Dr. Kadar makes the point that women receive more healthcare, as many tests and procedures, as much or even more research, and have benefitted more in terms of lifespan from medicine. Yet in spite of this people still claim there is a huge bias against women in medicine and medical research is not serving women well. I couldn't help think of the What have the Romans done for us bit from the Life of Brian during those combative conversations with people who were convinced that women weren't well served by medicine.

For me Dr. Kadar's article was important because of how it took on the main accusations that were levelled against medicine and countered each one with numbers, studies, and data. His article and work didn't stand alone. I recently found a longer piece by Cathy Young and Sally Satel written in 1997. The Myth of Gender Bias in Medicine was released by the Women's Freedom Network. The WFN's website is no more but the article is still online at another site. Yes it's online at a men's site. The article is online with the permission of Cathy Young but it's current form has a few obvious typos. Young and Satel go into more detail than Dr. Kadar. This makes their article hold even more weight with counter examples.

So gender bias doesn't exist? Or if it exists it is exclusively against men then?

No. I don't believe that at all. Gender bias in medicine does exist. Sometimes the bias favours men. Sometimes it favours women. Research money can never be allocated in such a way that there will be no discrepancies. There are certainly areas in which women suffer more than men and vice versa. There are conditions for both sexes that are underfunded and not well researched. Bias of all forms, gender included, does occur in medicine and medical research. There are diseases that affect only women and those that affect only men. Things get even more complicated when you're trying to figure out the impact on quality of life various diseases have instead of just looking at mortality numbers.

But that's not what people talk about. They don't talk about specific cases or particular areas. When research shows no bias against women it doesn't make the headlines. When research shows bias against men it rarely makes the headlines. And when research does show a bias against women the resulting articles tend to overstate and sensationalize the research in question.

Want a case in point? Okay... I'll provide one. It's an article called Women in Pain by Dr. Christina Lasich published on HealthCentral. This short article does a good job of reminding its readers that women do suffer from chronic and painful conditions more often then men. This results in pain that needs relief. The article hopes that as more research is done there will be more effective pain relief for women. So far I'm on board and agreeing completely. Chronic pain is an area that affects women more than men and research has shown that pain relief works differently in women than it does in men.

In the article though Dr. Lasich mentions a study called A Review of Clinical Research and Pain Management in Women and says:

[Witney McKiernan RN - the author of the study] found that the lack of help for women in pain is due in part to the lack of research specific to women in pain. Well, the FDA prohibited the participation of women in clinical drug trials for years. That ban did not start to thaw until the late 1980’s. Now, we have something called the Women’s Health Initiative; however, there continues to be discrimination in early clinical trials and researchers are still failing to account for gender differences when the study cohort does include women. In the past fifteen years with the inclusion of women in the research of chronic pain, many gender differences have already been discovered. PET scans have documented that women respond to pain differently than men.

First off she says there is a lack of research specific to women and then she finishes by saying that women have been included in research into chronic pain and differences have been discovered. Which is it? Let's see what the study itself says. The abstract for the paper in question says:

The involvement of women in clinical research has fluctuated in the course of recent medical history. Over the past fifteen years, the enactment of federal policies supporting gender-based research reflects a new appreciation of the importance of including women in clinical research. Women are increasingly participating in clinical trials for new drugs; however, gender-specific clinical data are lacking, suggesting the absence of data analysis to determine sex-related differences in the pharmacokinetics and pharmacodynamics of drugs. In this report, clinical trial data, meta-analyses, and literature reviews from the past 25 years are used to explore the barriers to in-depth clinical research on women and examine the implications of a research bias for pain management in women. While an extensive body of research on women and pain pharmaceuticals is currently being developed, there are myriad untapped opportunities for future research and policy that have the potential to supplement the knowledge base in this area and provide critical information to clinicians and patients.

The paper suggests that there may be an "absence of data analysis" not an absence of research and that "an extensive body of research on women and pain pharmaceuticals is currently being developed". There is no mention in the abstract of the lack of research mentioned in the article. In the article there is mention that there are "myriad untapped opportunities for future research and policy that have the potential to supplement the knowledge base" as the study points out. To me a myriad of oppurtunities doesn't point to a lack of research. It points to having enough existing research to know which areas to explore next.

I'll let you read the entire study (it's very interesting) but if you don't want to here's the conclusion:

A considerable amount of research demonstrates the importance of using gender-based information when treating pain in women. It is crucial that scientific research continue to support the exploration of sex-related differences in physiology, disease pathology, and the pharmacokinetics and pharmacodynamics of drugs so that women and their care providers can access accurate information and make informed health choices.

The study says one thing... the article another. Even if the two aren't polar opposites there are differences in how the conclusions in the study are presented. Which would you think is correct - that article or the actual study?

More importantly which would you and I be more likely to read from beginning to end? Me too... I'm more likely to read the article and assume the research is well summarized. Who has the time to read all the studies to make sure?

And am I the only one who finds it ironic that it took a lot of medical research into women's chronic pain and suffering, and medical research into the differences of pain between the sexes, and medical research into the implications of those differences... to give people enough information to then claim that medical research isn't doing enough to solve the problem? That there is a growing body of research into fibromyalgia and other chronic conditions should be seen as a good sign right? Not just evidence that there is bias. Even if there is bias currently... isn't the "considerable amount of research" and the "myriad untapped opportunities" signs of progress?

Then there are the accusations that there is conscious and/or unconscious bias among medical practitioners. Such as those mentioned in the Globe and Mail article.

Let me give you a perfect example of gender bias in action. An example of conscious or unconscious bias among medical practitioners. I'll use a "Comment" article in the Journal of Epidemiology and Community Health by M. T. Ruiz and L. M. Verbrugge called A two way view of gender bias in medicine (pdf).

First off if you're going to read it sit down and take a deep breath. It's not a study or a piece of research even though it sites many studies. It reads more like a modern deconstruction of an article about medical research. I think it's heart is in the right place but I think the execution stinks. As a "comment" it can cherry pick studies that support it's conclusion without being a balanced look at the whole field. That's not a bad thing when you're trying to change attitudes and convince people of your position. As I said I think it's heart is in the right place. At least the authors seem to be trying to move the discussion on gender bias forward.

The article's two way view isn't based on men vs women by the way. It's based on the fact that women are short changed when medical research assumes men and women are biologically similar and that women are short changed when medical research assumes men and women are biologically different.

According to the article it doesn't matter what medical researchers think... they're doing a diservice to women. Damned if they do. Damned if they don't.

Where's the conscious or unconscious bias? The bias is in how the authors treat the male gender. The authors never once suggest that there could be even a single case in which bias in medicine may be a bias against men. Apparently that can't happen.

I dare you. Go look yourself. I've found explicit statements in the article that there is a bias against women. I've found blanket statements that say there is bias without mentioning a gender but which seem to assume that the only bias is against women. But I couldn't find a single line that suggests that the bias may go the other way even in one case. To me that's an unconscious or unstated bias in the medical community.

When it comes to real biases in medicine we also have to be aware that trends are important. Even when one gender is doing better than the other the picture may not be rosy. In my Anatomy of a Comment I linked to a startling graph of Canadian lung cancer mortality rates. The rate of mortality for men is falling. Progress is being made. The rate for women is climbing. They haven't yet reached the same mortality level as men but that hasn't stopped cancer researchers from working to figure out what is going on. The goal isn't to find a perfect balance of mortality rates. The goal is to save and improve lives. Lung cancer kills more men than women. Based only on the mortality numbers more research and work should be done to help men exclusively. Yet based on the trends it's important to figure out why women's mortality rate is climbing. This trend is on the radar of the Canadian Cancer Society. After all they pointed the trend out to the public.

This is a good example of work being done for women when they aren't dying as often as men. Yet. But the goal isn't to balance the scorecard. The goal is to improve overall health for everyone.

So What Do I Think?

I said at the beginning that my answer on the question of gender bias in medicine is "No and Yes - in that order". Let me explain.

No. I don't think there is solid evidence of a systemic bias against women. I don't think you could make the case that there is a systemic bias against men either. Any such claim either way has a mountain of counter evidence to disprove. Extraordinary claims require extraordinary evidence. Claiming a systemic bias is an extraordinary claim.

So far I haven't seen enough convincing evidence that stands up to scrutiny to let the blanket claim against medicine stand.

Yes. Of course there is gender bias in medicine. Men and women are similar in many ways and different in many others. There are specific diseases and syndromes that are under researched and not well understood. Research money isn't always spread out fairly (and I'm not even sure that's possible). There are more than a few cases in which women could be better served. There are cases for men as well.

I'm more than willing to entertain discussion on specific cases, specific diseases, and specific research. I will try my best not to jump to the conclusion that bias doesn't or can't exist. In return allow me to be skeptical and check your numbers and your assumptions.

This is an important medical controversy. Much good work can be done to help redress the various imbalances that have appeared over time. I believe that the overall assumption that men are routinely better served than women does more harm than good in moving the discussion forward.

Feel free to disagree... I still have on my asbestos clothes.

If you've made it this far I thank you. I'm not done yet though. Let me tell you what I hope will happen to the discussions around gender bias in medicine. I'm too pragmatic (some would say cynical) to assume that people will take these seven suggestions to heart but I'm not cynical enough to not list them.

1) Let's admit that people have benefitted greatly from advances in medicine. We're all much better off now than people were one hundred years ago. Men and women have both been well served by medicine.

2) Don't assume there is a systemic bias against one sex or the other. If you do make that assumption be prepared for a lot of questions and a lot of criticism. You better bring one hell of a complete and detailed case to the table to even begin to be taken seriously.

3) Assume there are areas of gender bias in medicine. There will always be areas in which women or men aren't well served. Don't say they can't exist. Don't say that gender bias is impossible or not happening. These specific claims have to be taken seriously until they are disproved or shown to be valid. Advances in treatment and drugs may not serve both sexes equally. Of course this means that the areas that have a gender bias will change. Some will go away. Others will get worse. New ones will appear.

4) Please understand the difference between treatments and outcomes. Surgery isn't always the most effective course of treatment. More procedures for one gender may not mean better outcomes. You have to look at outcomes as well.

Different treatment guidelines exist for many diseases that depend on age, health, sex, weight, size, and other factors. When you hear "men get more this" or "women get less that" check to see which gender is getting the better outcomes. Try to determine if everyone is getting the most appropriate care necessary to receive the best possible outcomes.

If the outcomes are completely different between genders check if they've improved over time or if they are getting worse. Take the example of women and lung cancer mortality. Fewer women than men die of lung cancer yet the concern is why is the mortality rate for women rising while the rate for men is falling. Outcomes and trends are important in understanding if research and treatments are helping people.

5) Understand that research in an area doesn't necessarily guarantee results. Certainly not results right away. If a case of gender-bias is found and it seems that no progress is being made check to see the status of research before making accusations. Is there ongoing research? Are there discoveries and advances being made? Are there potential treatments and drugs in the works that haven't made it to clinical trials yet? And is the research taking time just due to the complexity of the subject matter?

A lot of money and research doesn't mean there will be a simple cure soon. Simple cures and therapies are discovered but you can't count on them.

Remember we've handled most of the easy diseases already. With the 'simple' ones taken care of we are living longer lives. Longer lives that are leading to new and challenging medical problems.

6) Even if this seems contrary to all I've said so far... it isn't. If you think there is an area where a gender isn't well served raise your voice and speak loudly and often. If you're concerned about an apparent inequality take the time to dig into the numbers a little and build your case. If you think it's a real problem raise a stink.

Be prepared for counter arguments. Be prepared for resistance. Keep raising a stink if it's required but please do so with humility and discussion. Bring facts to the discussion and not just accusations. Having facts and solid arguments on your side is more likely to get peoples attention in the medical and medical research communities than claims with no substance behind them.

Oh... and if you are more interested in muckraking, or ratings, or page views, or achieving best seller status, or getting on the talk show circuit, or in making political points then in having a useful discussion of the issue you're raising... then forgive me if I don't take you as seriously as someone who can back up their claims and is willing to be have those claims scrutinized.

7) Understand we all want to live longer. We all want a better quality of life along the way. Most of us will get it. Medicine has helped both men and women and it will continue to do so. Let's make the discussion be one of how medicine can do better for women and men instead of one where medicine is attacked, accused, and blamed.

In closing let me say I'm all for informed and sane discussion on gender bias in medicine. I know it exists. I know it will continue to exist. Over time some areas of gender bias will go away and others will be discovered. Maybe we've reached the point where the 'simpler' diseases have been taken care of. We don't die of tuberculosis. Smallpox isn't ravaging millions. Antibiotics and other wonder drugs are common place.

More and more we're left with the more complicated syndromes and diseases. We're left with the ones where gender differences have to be taken into consideration in treatment and research. We're left needing to make sure that gender and other factors are taken into consideration. What we need is to be open to informed discussions so better decisions can be made.

I don't think blanket and baseless accusations help this discussion at all.

And if you think we still need the blanket accusations and that I'm completely full of it... I'm not worried. I'm still wearing my flame proof suit.