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As originally published in The Atlantic
Monthly
August 1994
The Sex-Bias Myth in Medicine
Though it is commonly believed that American health-care delivery and research
benefit men at the expense of women, the truth appears to be exactly the
opposite
by Andrew G. Kadar, M.D.
"When it comes to health-care research and delivery, women can no longer be
treated as second-class citizens." So said the President of the United States
on October 18, 1993.
He and the First Lady had just hosted a reception for the National Breast
Cancer Coalition, an advocacy group, after receiving a petition containing 2.6
million signatures which demanded increased funding for breast-cancer
prevention and treatment. While the Clintons met with leaders of the group in
the East Room of the White House, a thousand demonstrators rallied across the
street in support. The President echoed their call, decrying the neglect of
medical care for women.
Two years earlier Bernadine Healy, then the director of the National Institutes
of Health, charged that "women have all too often been treated less than
equally in . . . health care." More recently Representative Pat Schroeder, a
co-chair of the Congressional Caucus for Women's Issues, sponsored legislation
to "ensure that biomedical research does not once again overlook women and
their health." Newspaper articles expressed similar sentiments.
The list of accusations is long and startling. Women's-health-care advocates
indict "sex-biased" doctors for stereotyping women as hysterical
hypochondriacs, for taking women's complaints less seriously than men's, and
for giving them less thorough diagnostic workups. A study conducted at the
University of California at San Diego in 1979 concluded that men's complaints
of back pain, chest pain, dizziness, fatigue, and headache more often resulted
in extensive workups than did similar complaints from women. Hard scientific
evidence therefore seemed to confirm women's anecdotal reports.
Men more often than women undergo angiographies and
coronary-artery-bypass-graft operations. Even though heart disease is the No. 1
killer of women as well as men, this sophisticated, state-of-the-art
technology, critics contend, is selectively denied to women.
The problem is said to be repeated in medical research: women, critics argue,
are routinely ignored in favor of men. When the NIH inventoried all the
research it had funded in 1987, the money spent on studying diseases unique to
women amounted to only 13.5 percent of the total research budget.
Perhaps the most emotionally charged disease for women is breast cancer. If a
tumor devastated men on a similar scale, critics say, we would declare a state
of national emergency and launch a no-cost-barred Apollo Project-style program
to cure it. In the words of Matilda Cuomo, the wife of the governor of New
York, "If we can send a woman to the moon, we can surely find a cure for breast
cancer." The neglect of breast-cancer research, we have been told, is both
sexist and a national disgrace.
Nearly all heart-disease research is said to be conducted on men, with the
conclusions blindly generalized to women. In July of 1989 researchers from the
Harvard Medical School reported the results of a five-year study on the effects
of aspirin in preventing cardiovascular disease in 22,071 male physicians.
Thousands of men were studied, but not one woman: women's health, critics
charge, was obviously not considered important enough to explore similarly.
Here, they say, we have definite, smoking-gun evidence of the neglect of women
in medical research--only one example of a widespread, dangerous phenomenon.
Still another difference: pharmaceutical companies make a policy of giving new
drugs to men first, while women wait to benefit from the advances. And even
then the medicines are often inadequately tested on women.
To remedy all this neglect, we need to devote preferential attention and funds,
in the words of the Journal of the American Medical Women's Association, to
"the greatest resource this country will ever have, namely, the health of its
women." Discrimination on such a large scale cries out for restitution--if the
charges are true.
In fact one sex does appear to be favored in the amount of attention devoted to
its medical needs. In the United States it is estimated that one sex spends
twice as much money on health care as the other does. The NIH also spends twice
as much money on research into the diseases specific to one sex as it does on
research into those specific to the other, and only one sex has a section of
the NIH devoted entirely to the study of diseases afflicting it. That sex is
not men, however. It is women.
IN the United States women seek out and consequently receive more medical care
than men. This is true even if pregnancy-related care is excluded. Department
of Health and Human Services surveys show that women visit doctors more often
than men, are hospitalized more often, and undergo more operations. Women are
more likely than men to visit a doctor for a general physical exam when they
are feeling well, and complain of symptoms more often. Thus two out of every
three health-care dollars are spent by women.
Quantity, of course, does not guarantee quality. Do women receive second-rate
diagnostic workups?
The 1979 San Diego study, which concluded that men's complaints more often led
to extensive workups than did women's, used the charts of 104 men and women
(fifty-two married couples) as data. This small-scale regional survey prompted
a more extensive national review of 46,868 office visits. The results, reported
in 1981, were quite different from those of the San Diego study.
In this larger, more representative sample, the care received by men and women
was similar about two thirds of the time. When the care was different, women
overall received more diagnostic tests and treatment--more lab tests,
blood-pressure checks, drug prescriptions, and return appointments.
Several other, small-scale studies have weighed in on both sides of this issue.
The San Diego researchers looked at another 200 men and women in 1984, and this
time found "no significant differences in the extent and content" of workups.
Some women's-health-care advocates have chosen to ignore data from the second
San Diego study and the national survey while touting the first study as
evidence that doctors, to quote once again from the Journal of the American
Medical Women's Association, do "not take complaints as seriously" when they
come from women: "an example of a double standard influencing diagnostic
workups."
When prescribing care for heart disease, doctors consider such factors as age,
other medical problems, and the likelihood that the patient will benefit from
testing and surgery. Coronary-artery disease afflicts men at a much younger
age, killing them three times as often as women until age sixty-five. Younger
patients have fewer additional medical problems that preclude aggressive,
high-risk procedures. And smaller patients have smaller coronary arteries,
which become obstructed more often after surgery. Whereas this is true for both
sexes, obviously more women fit into the smaller-patient category. When these
differences are factored in, sex divergence in cardiac care begins to fade
away.
To the extent that divergence remains, women may be getting better treatment.
At least that was the conclusion of a University of North Carolina/Duke
University study that looked at the records of 5,795 patients treated from 1969
to 1984. The most symptomatic and severely diseased men and women were equally
likely to be referred for bypass surgery. Among the patients with less-severe
disease--the ones to whom surgery offers little or no survival benefit over
medical therapy--women were less likely to be scheduled for bypass surgery.
This seems proper in light of the greater risk of surgical complications, owing
to women's smaller coronary arteries. In fact, the researchers questioned the
wisdom of surgery in the less symptomatic men and suggested that "the effect of
gender on treatment selection may have led to more appropriate treatment of
women."
As for sophisticated, pioneering technology selectively designed for the
benefit of one sex, laparoscopic surgery was largely confined to gynecology for
more than twenty years. Using viewing and manipulating instruments that can be
inserted into the abdomen through keyhole-sized incisions, doctors are able to
diagnose and repair, sparing the patient a larger incision and a longer, more
painful recuperation. Laparoscopic tubal sterilization, first performed in
1936, became common practice in the late 1960s. Over time the development of
more-versatile instruments and of fiber-optic video capability made possible
the performance of more-complex operations. The laparoscopic removal of ectopic
pregnancy was reported in 1973. Finally, in 1987, the same technology was
applied in gallbladder surgery, and men began to enjoy its benefits too.
Years after ultrasound instruments were designed to look inside the uterus, the
same technology was adapted to search for tumors in the prostate. Other
pioneering developments conceived to improve the health care of women include
mammography, bone-density testing for osteoporosis, surgery to alleviate
bladder incontinence, hormone therapy to relieve the symptoms of menopause, and
a host of procedures, including in vitro fertilization, developed to facilitate
impregnation. Perhaps so many new developments occur in women's health care
because one branch of medicine and a group of doctors, gynecologists, are
explicitly concerned with the health of women. No corresponding group of
doctors is dedicated to the care of men.
So women receive more care than men, sometimes receive better care than men,
and benefit more than men do from some developing technologies. This hardly
looks like proof that women's health is viewed as secondary in importance to
men's health.
THE 1987 NIH inventory did indeed find that only 13.5 percent of the NIH
research budget was devoted to studying diseases unique to women. But 80
percent of the budget went into research for the benefit of both sexes,
including basic research in fields such as genetics and immunology and also
research into diseases such as lymphoma, arthritis, and sickle-cell anemia.
Both men and women suffer from these ailments, and both sexes served as study
subjects. The remaining 6.5 percent of NIH research funds were devoted to
afflictions unique to men. Oddly, the women's 13.5 percent has been cited as
evidence of neglect. The much smaller men's share of the budget is rarely
mentioned in these references.
As for breast cancer, the second most lethal malignancy in females,
investigation in that field has long received more funding from the National
Cancer Institute than any other tumor research, though lung cancer heads the
list of fatal tumors for both sexes. The second most lethal malignancy in males
is also a sex-specific tumor: prostate cancer. Last year approximately 46,000
women succumbed to breast cancer and 35,000 men to prostate cancer; the NCI
spent $213.7 million on breast-cancer research and $51.1 million on study of
the prostate. Thus although about a third more women died of breast cancer than
men of prostate cancer, breast-cancer research received more than four times
the funding. More than three times as much money per fatality was spent on the
women's disease. Breast cancer accounted for 8.8 percent of cancer fatalities
in the United States and for 13 percent of the NCI research budget; the
corresponding figures for prostate cancer were 6.7 percent of fatalities and
three percent of the funding. The spending for breast-cancer research is
projected to increase by 23 percent this year, to $262.9 million;
prostate-research spending will increase by 7.6 percent, to $55 million.
The female cancers of the cervix and the uterus accounted for 10,100 deaths and
$48.5 million in research last year, and ovarian cancer accounted for 13,300
deaths and $32.5 million in research. Thus the research funding for all
female-specific cancers is substantially larger per fatality than the funding
for prostate cancer.
Is this level of spending on women's health just a recent development, needed
to make up for years of prior neglect? The NCI is divided into sections dealing
with issues such as cancer biology and diagnosis, prevention and control,
etiology, and treatment. Until funding allocations for sex-specific concerns
became a political issue, in the mid-1980s, the NCI did not track
organ-specific spending data. The earliest information now available was
reconstructed retroactively to 1981. Nevertheless, these early data provide a
window on spending patterns in the era before political pressure began to
intensify for more research on women. Each year from 1981 to 1985 funding for
breast-cancer research exceeded funding for prostate cancer by a ratio of
roughly five to one. A rational, nonpolitical explanation for this is that
breast cancer attacks a larger number of patients, at a younger age. In any
event, the data fail to support claims that women were neglected in that era.
Again, most medical research is conducted on diseases that afflict both sexes.
Women's-health advocates charge that we collect data from studies of men and
then extrapolate to women. A look at the actual data reveals a different
reality.
The best-known and most ambitious study of cardiovascular health over time
began in the town of Framingham, Massachusetts, in 1948. Researchers started
with 2,336 men and 2,873 women aged thirty to sixty-two, and have followed the
survivors of this group with biennial physical exams and lab tests for more
than forty-five years. In this and many other observational studies women have
been well represented.
With respect to the aspirin study, the researchers at Harvard Medical School
did not focus exclusively on men. Both sexes were studied nearly concurrently.
The men's study was more rigorous, because it was placebo-controlled (that is,
some subjects were randomly assigned to receive placebos instead of aspirin);
the women's study was based on responses to questionnaires sent to nurses and a
review of medical records. The women's study, however, followed nearly four
times as many subjects as the men's study (87,678 versus 22,071), and it
followed its subjects for a year longer (six versus five) than the men's study
did. The results of the men's study were reported in the New England Journal of
Medicine in July of 1989 and prompted charges of sexism in medical research.
The women's-study results were printed in the Journal of the American Medical
Association in July of 1991, and were generally ignored by the nonmedical
press.
Most studies on the prevention of "premature" (occurring in people under age
sixty-five) coronary-artery disease have, in fact, been conducted on men. Since
middle-aged women have a much lower incidence of this illness than their male
counterparts (they provide less than a third as many cases), documenting the
preventive effect of a given treatment in these women is much more difficult.
More experiments were conducted on men not because women were considered less
important but because women suffer less from this disease. Older women do
develop coronary disease (albeit at a lower rate than older men), but the
experiments were not performed on older men either. At most the data suggest an
emphasis on the prevention of disease in younger people.
Incidentally, all clinical breast-cancer research currently funded by the NCI
is being conducted on women, even though 300 men a year die of this tumor. Do
studies on the prevention of breast cancer which specifically exclude males
signify a neglect of men's health? Or should a disease be studied in the group
most at risk? Obviously, the coronary-disease research situation and the
breast-cancer research situation are not equivalent, but together they do serve
to illustrate a point: diseases are most often studied in the highest-risk
group, regardless of sex.
What about all the new drug tests that exclude women? Don't they prove the
pharmaceutical industry's insensitivity to and disregard for females?
The Food and Drug Administration divides human testing of new medicines into
three stages. Phase 1 studies are done on a small number of volunteers over a
brief period of time, primarily to test safety. Phase 2 studies typically
involve a few hundred patients and are designed to look more closely at safety
and effectiveness. Phase 3 tests precede approval for commercial release and
generally include several thousand patients.
In 1977 the FDA issued guidelines that specifically excluded women with
"childbearing potential" from phase 1 and early phase 2 studies; they were to
be included in late phase 2 and phase 3 trials in proportion to their expected
use of the medication. FDA surveys conducted in 1983 and 1988 showed that the
two sexes had been proportionally represented in clinical trials by the time
drugs were approved for release.
The 1977 guidelines codified a policy already informally in effect since the
thalidomide tragedy shocked the world in 1962. The births of armless or
otherwise deformed babies in that era dramatically highlighted the special
risks incurred when fertile women ingest drugs. So the policy of excluding such
women from the early phases of drug testing arose out of concern, not out of
disregard, for them. The policy was changed last year, as a consequence of
political protest and recognition that early studies in both sexes might better
direct testing.
THROUGHOUT human history from antiquity until the beginning of this century
men, on the average, lived slightly longer than women. By 1920 women's life
expectancy in the United States was one year greater than men's (54.6 years
versus 53.6). After that the gap increased steadily, to 3.5 years in 1930, 4.4
years in 1940, 5.5 in 1950, 6.5 in 1960, and 7.7 in 1970. For the past quarter
of a century the gap has remained relatively steady: around seven years. In
1990 the figure was seven years (78.8 versus 71.8).
Thus in the latter part of the twentieth century women live about 10 percent
longer than men. A significant part of the reason for this is medical care.
In past centuries complications during childbirth were a major cause of
traumatic death in women. Medical advances have dramatically eliminated most of
this risk. Infections such as smallpox, cholera, and tuberculosis killed large
numbers of men and women at similar ages. The elimination of infection as the
dominant cause of death has boosted the prominence of diseases that selectively
afflict men earlier in life.
Age-adjusted mortality rates for men are higher for all twelve leading causes
of death, including heart disease, stroke, cancer, lung disease (emphysema and
pneumonia), liver disease (cirrhosis), suicide, and homicide. We have come to
accept women's longer life span as natural, the consequence of their greater
biological fitness. Yet this greater fitness never manifested itself in all the
millennia of human history that preceded the present era and its medical-care
system--the same system that women's-health advocates accuse of neglecting the
female sex.
To remedy the alleged neglect, an Office of Research on Women's Health was
established by the NIH in 1990. In 1991 the NIH launched its largest
epidemiological project ever, the Women's Health Initiative. Costing more than
$600 million, this fifteen-year program will study the effects of estrogen
therapy, diet, dietary supplements, and exercise on heart disease, breast
cancer, colon cancer, osteoporosis, and other diseases in 160,000
postmenopausal women. The study is ambitious in scope and may well result in
many advances in the care of older women.
What it will not do is close the "medical gender gap," the difference in the
quality of care given the two sexes. The reason is that the gap does not favor
men. As we have seen, women receive more medical care and benefit more from
medical research. The net result is the most important gap of all: seven years,
10 percent of life.
Copyright © 1994 by Andrew G. Kadar. All rights
reserved.
The Atlantic Monthly; August 1994; The Sex-Bias Myth in Medicine; Volume
274, No. 2;
pages 66-70.
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