Despite forming half of the British population, women continue to suffer from persistent and significant gender inequalities in modern medical research and practice. The impact of this pernicious erasure of the female body, which can be seen in research, diagnostic waits, and even in a doctor’s perception of a patient’s physical pain level, leads to worse health outcomes for women.
The state of endometriosis care in the UK is illustrative of the long-term effects of medical bias against women. This female-only condition results in debilitating pain by causing uterine tissue to grow on other organs, such as the liver or bladder. Two million women in the UK have endometriosis. In 2019, the largest study of its kind found that severe diagnostic delays leave UK women to suffer with endometriosis for an average of seven and a half years. By this late stage, the condition can be severe enough to result in infertility and life-long pelvic problems. Of 13,500 women with endometriosis surveyed by the BBC in 2019, half said the pain had led to suicidal thoughts.
Repeated studies have shown that medical professionals take female pain less seriously. One study found that women with acute abdominal pain who present themselves to an emergency department are not only less likely to be given effective painkillers than men, they must also wait longer to actually receive them. Women’s pain is also less likely to be perceived as having a physical, organic cause. Instead, they are more likely to be referred for psychiatric help. Such attitudes are a major contributing factor to the average endometriosis diagnosis wait-time of seven and a half years. The effect can also be seen in the context of heart disease; women suffering heart attacks are 50% more likely than men to be initially misdiagnosed and, in England and Wales, are 7.4% less likely to be prescribed important preventative medications when leaving hospital following a heart attack.
Even drugs are often not as safe or efficacious for women as they are for men. Sex has a startling effect on drug response; early male-only studies of aspirin showed that the drug had a clear protective effect against heart disease. A female-only study did not find the same; in women aspirin reduces stroke risk but not heart attack risk, whilst in men the opposite is true. The reasons for and extent of sex divergence in aspirin’s effects are not totally understood, yet it is one of the world’s most common medications. Though women are known to metabolise medications differently, clinical trials frequently fail to take this into consideration; a 2014 report condemned this state of affairs as ‘leaving women’s health to chance’.
The lack of understanding on how commonplace drugs like aspirin affect the female body is at least in part due to the fact that, until the early 1990s, the exclusion of women from medical trials was the norm; it was thought that treatments that worked well for men would work for women too. Furthermore, it was simpler when designing a new study to build upon older research that had also been male-only. Even studies on heart disease, which is the leading killer of women in the UK and US, were predominantly male-only until the mid-1990s. Today only a third of cardiovascular clinical trial subjects are women and only 31% of such trials report their results by sex.
As clinical trials continue to be weighted towards men, it is possible that many drugs continue to be less efficacious for women. A frequent explanation for the exclusion of women today is ‘the complexities of the menstrual cycle’. The menstrual cycle does undoubtedly result in hormonal changes in the body which could have an impact on the effect of drugs. However, it is also a regular and predictable event that will occur throughout much of a woman’s life, making excluding women from trials illogical, considering that drugs are taken during the cycle.
The European Medicines Agency released a report in 2005 which argued that guidelines on including women in trials were unnecessary as gender representation was now adequate, but in 2019 new analysis of 1.5 million biomedical studies found that only one in three reported sex-related differences. Thus, whilst improving, an understanding gap around how drugs affect women persists.
The issue of imbalance in medical trials is in some senses easier to fix than the wider issue at hand here; clearer guidance can be released, sex-specific reporting can be made compulsory. However, what endometriosis diagnosis delays, in conjunction with medical attitudes to female pain, highlight is a much thornier and deep-rooted issue. Patients must self-report their pain to medical professionals, and that communication is affected by implicit biases. Unconscious bias training courses have become fairly commonplace in the public and private sector; perhaps it is time to consider a similar model for medical professionals.
Phoebe Arslanagić-Wakefield is a Research Assistant at Bright Blue.
