The gender health gap.

Published in

KAVITA Collection

12 min readMar 7, 2021

Based on a recent personal experience, I became passionately interested in the topic of how sex and gender impact health. With the following text, I want to provide you with an intro, food for thought, and build more awareness.
I am however not a medical professional, so for more detailed questions, I encourage you to start making yourself more familiar with the topic (links are listed at the end) and reach out to your doctor(s).

Taken from a Harvard health newsletter [1]

What is the gender health gap?

The World Health Organization (WHO) summarizes the gender health gap as follows: „Being a man or a woman has a significant impact on health, as a result of both biological and gender-related differences“ [2]. So, in the same way gender discrimination affects pay and relationships, it is also impacting our health.

Wait, you may say now, it is commonly known that women on average live longer than men [3] — so how can this be an important topic to raise awareness for specifically in the context of women’s health?

While “gender-specific medicine” has its roots in the feminist movement, focusing on women’s health does not mean ignoring or deprioritizing men’s health. It’s about acknowledging that

women and men are different — in how they catch and react to a disease or in how they are diagnosed and treated.
and that factors that influence health negatively, on a global scale disproportionately impact women.

The following are key factors that influence equal opportunity in health resulting from our sex and gender:

Medical reasons
Women’s health topics have long been limited to our reproduction system. Past medical research often worked on the assumption that, with the exceptions of issues related to this reproductive system, women are just like men. And the male body was taken as the default. As a result, in fields as diverse as brain cancer, chronic pain, heart attacks, and dementia, women are often misdiagnosed and undertreated.
But even in the area of our reproductive system, there’s a lack of accurate diagnosis. Take endometriosis for example, a rather painful gynecological issue that affects 1 in 10 women —for a diagnosis it can take up to 8-10 years because symptoms are often dismissed as ordinary period pain and not investigated.
Sociocultural reasons
Women’s health is influenced not only by our biology but by discrimination rooted in sociocultural factors such as unequal power relationships between men and women, unequal access to wealth or employment, family responsibilities, and violence. These factors for example restrict access to health care and knowledge. And the greater the level of disadvantage, such as in developing countries, the greater is the negative impact on health.
Lack of equal opportunities also arises from cultural norms and biases, that influence how female (or male) patients describe their symptoms and how medical personnel interprets those.

The combination of both factors also leads to a lack of funding in this area. In a recent analysis for the US [4], it was found that for nearly three-quarters of the cases where a disease effects primarily one gender, the funding pattern favors males: either the disease affects more women and is underfunded — or the disease affects more men and is overfunded.
Take as an example the premenstrual syndrome (PMS), which is estimated to affect 75 -90% of women. PMS exhibits a wide variety of signs and symptoms, including mood swings, tender breasts, food cravings, fatigue, irritability, and depression. There’s roughly five times more funding available for erectile dysfunction than PMS, though it affects “only” 19% of men [5].

Women’s health and sexuality was (and still is) often a mystery

Before I go into describing the gender biases that exist today in medical research, diagnosis, treatment, and education, let me take you on a time travel back into history. Only with this context, the state of knowledge on the functionality of the female body, and the prevalent gender biases in health become more clear and understandable.

Firstly, one of the root causes of a lack of understanding and knowledge on women’s health and sexuality is likely related to the role women played in the medical field throughout history. In the last centuries, women were banned from the medical profession and had no access to formal medical education (except for nursing and midwifery and some notable exceptions, see [6]). According to [7], only 5.5% of students entering medical school in the US were women in 1949, In 1974 this rate grew to 22.4% and by the end of the 20th century, that number rose to 45.6%.
Another key role in history played “hysteria” [8], an illness that was considered very common and chronic in women. It still has a (mostly unconscious) impact today.
Tales say that the word originally stems from the Egyptians or Greek. With this term they were describing a wandering uterus seeking a child in the female body, explaining many physical symptoms women had.
Later on, the term described a wide range of conditions in women, including insomnia, pain, spasms, lack of or too much sexual desire, and excessive emotions. Practically, a lot of hysteria’s symptoms were synonymous with what we’d describe today as a normal functioning female sexuality, in addition to a set of mental illnesses. Freud then made “hysteria” even more well-known as a mental illness — he related it to repressed childhood fantasies and built upon this his theory of the Oedipus complex, which connotes femininity as a failure (or lack of masculinity).
While today we have a much better understanding of a set of mental illnesses that once were all described by hysteria, the American Psychiatric Association didn’t drop the term until the early 1950s. The impact of this medical diagnosis can still be felt today: “crazy” and “hysterical” labels are still hard for women to completely shake off. This history also leads to women’s description of symptoms being not taken as seriously or vastly misunderstood.
For a long time, the only acknowledged physical difference was the reproduction system of women. Otherwise, the bodies were concluded the same. In addition, in earlier times women usually had a large number of pregnancies and in the past, childbirth itself was risky and frequently led to the death of the mother. As a result, many women did not even live long enough to be concerned about menopause or old age.
Last, due to social and cultural reasons, talking about sexuality and desire was long seen as taboo, especially for women (and often still is today). This results in a lack of knowledge about how a female body functions and also leads to shame bringing up and talking about any dysfunctions. While this wide topic is more suitable for a separate article, I’ll give just two simple examples here:
(a) What most people call the vagina, is actually the vulva — and what role the female orgasm plays for reproduction and whether the G point really exists is still debated by scientists.
(b) The hymen simply can’t indicate whether a woman is still a virgin or not — being a virgin is a social construct, not a medical fact.

Gender bias in medical and pharmaceutical research

Whenever we get prescribed a medication by a doctor, we trust that there’s scientific evidence this medication will help us. If you are male, you can likely have a high trust — if you are a woman you can’t.
For example, Aspirin has long been promoted to reduce the risk for heart attacks, but recently it was found that this is only true for men. There is no effect for women — instead, it was found that Aspirin reduces the risk of strokes for women, but not for men [9]. As a matter of fact, a lot of drugs withdrawn from the US market are due to side effects for women [10]. And according to [11], more than 98 percent of medications available in the US have no or insufficient safety data to guide dosing during pregnancy.

Bringing a new medication to the market is an expensive and very research-intensive long-term endeavor. It often starts with cell studies in laboratories, followed by animal studies and if all goes well clinical trials are run. The problem is that the cells used are mainly male cells, the animals are mainly male animals, and the clinical trials have also been performed almost exclusively on men.

The reasons for not including women for example in clinical trials, even today, are mainly due to the complexity that arises from a woman’s hormonal system which in turn make those studies more expensive and time-intensive. There’s also the ethical question around what if something happens to the fetus if a woman becomes pregnant — or is pregnant — during a study.
Even if women are today included in trials, they tend to be tested in a very specific phase of the menstrual cycle when hormone levels are at their lowest to minimize the impact the hormones have on the study. But as stated in [12], “real life isn’t a study and in real life, those pesky hormones will have an impact on outcomes. So far, menstrual cycle impacts have been found for antipsychotics, antihistamines, antibiotic treatment as well as heart medication.”

A growing body of evidence indicates that females process pain differently than males. But many lab scientists who study ways of treating pain still use cohorts of only male lab mice, with the same argument again that male mice aren’t as hormonal as females and are therefore more reliable in terms of getting data. See [12] or [13] for more.

The problem with using male cells only is more hidden. The problem here is that male and female cells can react very differently to specific treatments. But because studies are stopped if male cells show no effect, we don’t know what treatment for women may have been missed because there was no effect on male cells.

Gender bias in diagnosis, treatment, and prevention

While chronic pain and pain sensitivity is more prevalent in women than men ([14] and [15]), studies show that women are more likely to be diagnosed with pain being an emotional response rather than having a physiological cause. This means women are more likely to be prescribed sedatives than pain medicine — and because of the way the female and male bodies process and feels pain differently, medication leads to different effects for men and women (which are as described above, largely unknown).

Life-threatening examples of gender bias [16] include a 50% higher chance to receive an incorrect initial diagnosis for a heart attack — and if diagnosed correctly also having higher rates of death during hospitalization. Or a 30% higher chance to have symptoms of a stroke misdiagnosed and be sent home from the emergency room. Another key factor that plays a role in these cardiovascular diseases being detected in the first place is the sociocultural factor — women are less likely to seek an early diagnosis because these diseases are often seen as affecting mainly men (while for both sexes a heart attack remains the leading cause of death).

When it comes to prevention, vaccinations have proven in the past as effective means to reduce infection and mortality rates. However, there’s also a recent indication that sex and gender impact vaccine acceptance, responses, and outcomes [17] — women generally tend to develop higher antibody responses (i.e. for influenza) and report more adverse effects of vaccination (i.e. measles).

Lastly (as hinted at in some of the examples I have throughout the text), many female-specific conditions and diseases, like period pain, endometriosis, polycystic ovary syndrome, premenstrual syndrome, and vaginismus are woefully under-researched, with their causes and treatments unknown. And until recently, as soon as women experienced issues related to their menopause, they have been simply described a hormone replacement therapy by default without looking at alternatives that can better support women going through this phase in their life.

Gender bias in medical education

The Charité — the largest academic hospital in Germany, played a key role in establishing research around gender-specific topics in medicine and formally formulating a curriculum to teach and create awareness on gender-specific topics in an interdisciplinary way. The Institute of Gender in Medicine (GIM) was founded in 2003. Most other universities in Germany only slowly include these topics into their medical education — starting often only by offering gender medicine as a single voluntary subject, without integrating it more broadly into the common subjects where diseases, their diagnosis, and treatments are being taught. The same is true for a lot of other countries in the world.

Many of the gender biases, that impact research, diagnoses, and treatment are also a direct result of how health professionals are being educated. But it’s not only the medical professionals, whose education needs to be addressed, it’s also the knowledge and awareness of the public that needs to change. Sex education plays a key part of it, which is still left with a lot of taboos and stigma even today, keeping those biases well alive that impact gender-specific health. [18] is a book I can highly recommend not only any young adult but any women and men to read in this context.

Case Study: Sex, gender and Covid 19

I think it’s fair to conclude that during the ongoing pandemic, all of us started to have more interest in understanding the impact that Covid 19 has on our lives and health. I thus dug a bit into statistics to use this as an interesting showcase.

From a medical perspective, it’s positive to see that more and more countries for example start to collecting sex-disaggregated data that help understand how our sex and gender impact our Covid 19 risks and prevention:

Take Germany for example, where we see in [19] that while women are slightly more likely to get infected, men are more likely to suffer severe cases or die. The higher mortality risk is assumed to stem from a prevalence of particular preexisting conditions in men (maybe resulting from heavier smoking… ). The slightly higher infection risk is assumed to stem from the fact that women are more exposed to the virus due to their employment (i.e. more healthcare workers and supermarket assistants are female).
Most vaccine trial studies seem to have an equally distributed number of participants of both genders.
Pfizer reported in [20] that the effectiveness of the vaccine was consistent across age, gender, race, and ethnicity demographics. Studies on the effectiveness in pregnant women have just recently started [22].
For the Moderna vaccine, there’s a recent article higlighting that women experience more severe side effects than men do [26].

On the contrary, from a socio-cultural and economic aspect, the impact the pandemic has on women is rather severe [22]. These factors in turn influence the women’s health long term.

Economic impacts as a result of measures implemented to stop the pandemic are felt especially by women and girls. They are generally earning less, saving less, holding insecure / part-time jobs, or are at higher risk of poverty.
While more men are dying as a result of COVID-19, the health of women is adversely impacted through the reallocation of resources and priorities, including sexual and reproductive health services.
Unpaid care work for women has increased — with children being homeschooled or due to care needs of older relatives.
Gender-based violence is increasing. The key problem is that during lockdowns and curfews, victims have much harder times seeking help as they are literally trapped at home — and we’ll only see the full impact once the pandemic is over. It’s even so severe that it's called the “shadow pandemic” by the UN [23].

With this rather long article, I barely scratched the surface of (the history of) gender-specific health gaps and how these affect women. Besides the topics I touched on and the examples I gave, I also wanted to highlight that there is also a noteworthy intersection of gender and racial bias in medical research, diagnosis, and treatment which I did not cover in my article (for a starter on this see [24]). And yes, there’s also a health gap for men [25]. I’m also aware that I did not sufficiently highlight the issues women face in developing countries vs. the developed world.

As stated at the beginning, gender specific medicine does not mean to prioritize a women’s health over a men’s health, it is a about providing equal opportunities irrespecive of factors such as sex or gender — towards a more individualized health care for everyone.

For the curious, I added below all the references from my article and a few more links and books to read. Any recommendations for further reading material to add to this list and respectful comments and personal messages are warmly welcome!