The pill of gender bias – hard to swallow

This article was exclusively written for The European Sting by Ms. Manali Sarkar, a 2nd year MBSS student at MGM Medical College, Navi Mumbai. She is affiliated to the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong strictly to the writer and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.

Medicine has not taken the intricacies of the female body into account – and so “women’s health” became synonymous with reproductive organs. It was only during the 21^st century that such obsolete ideas were challenged by the emergence of evidence that women experience heart attacks differently than men. The difference comes right down to the cellular levels. Research published by Israel’s Weizmann Institute of Science in 2017 found that around a third of the 20,000 genes present in a cell express themselves differently in males and females^[1]. Yet, why is the unique physiology of a woman not taken into consideration? How can we as medical students change this?

One way is using an equal number of male and female mice during research. Among 1200 neuroscience papers from 2011 and 2012, only 42% reported the sex of the mice used of which only 24% were female^[2]. Secondly, we need a gender specific approach to any treatment procedure. Kautzky-Willer’s research specializes in diabetes and she has found that women usually have a lower fasting glucose and HbA1C than men. She hypothesizes that a separate blood test with different cutoffs or biomarkers will be needed to diagnose diabetes in men and women^[3]. Similar conclusions are occurring in varying fields of medicine; for example, women are more sensitive to antihistaminic drugs and aspirin is more effective in stroke prevention in woman but heart attacks in males etc^[4].

Unfortunately, findings such as these have not had widespread impact on diagnosis and treatment. A vast majority of diagnoses, therapies and drug dosages for common conditions are still based on symptoms, responses and outcomes in Caucasian adult males.  Berga says that there are two things going on at once- “One is the urge to simplify to make things efficient, to arrive at something that’s one size fit all. The other is that if something does not work in one size fits all model, then you have to find the reason and determine what should be changed, and you run into questions about how much it will cost to do this, how long it will take and so on” ^[5].

The “one size fits all” theory can be disproven by having an inclusive list of participants. A 2010 study from the Duke Clinical Research Institute in the USA found that only a quarter of those involved in coronary artery disease trials are women ^[6]. Shockingly enough the study to demonstrate alcohol interaction with Flibanserin (a drug which was passed by the FDA for treatment of hypoactive sexual desire disorder in premenopausal women) enrolled 23 men and 2 women and thus many researchers like Dr. Mazure expressed concern over the nature of the study ^[7]. Medical students should also acknowledge the limitations of medicine with respect to women instead of dismissing them as “hysterical” and invalidating their negative experiences. Dr.Young reports of how women who were ineffectively treated by current medication of endometriosis were labeled as “difficult” ^[8].

Thankfully not all hope is lost. In 2013, the FDA applied new recommendations for lowering the dosage of drugs containing active ingredient Zolpidem^[9]. In 2016 the NIH began to mandate that research should include female animals ^[10].

^[1] Pietrokovski, Shmuel and Gershoni, Moran. “Differences in male vs. female gene expression drive infertility,” Weizmann Compass, 2017. http://www.weizmann.ac.il/WeizmannCompass/sections/briefs/in-sickness-and-in-health.

^[2] Rozenbaum, Mia. “Why we need female mice in drug trials,” Understanding Animal Research, 2019. https://www.understandinganimalresearch.org.uk/news/communications-media/why-we-need-female-mice-in-drug-trials/.

^[3] Crompton, Simon. “Should medicine be gendered,” BBC Science Focus Magazine, 2019.  https://www.sciencefocus.com/the-human-body/should-medicine-be-gendered/.

^[4] Soldin, Offie P., Chung, Sarah H., and Mattison, Donald R. “Sex Differences in Drug Disposition,” Journal of Biomedicine and Biotechnology, 2011.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051160/.

^[5] “Medicine Looking Deeper Into Vital Differences Between Women and Men,” Wake Forest Baptist Health. Date accessed: Sept. 27 2020.https://www.wakehealth.edu/Stories/Differences-Between-Men-and-Women.

^[6] Shen, Lan and Melloni, Chiara. “Representation of Women in Randomized Clinical Trials of Cardiovascular Disease Prevention,” ,2014. https://link-springer-com.subzero.lib.uoguelph.ca/article/10.1007/s12170-014-0390-9.

^[7] Harrison, Rick. “Safety of Drinking with New Female Libido Drug Tested in Mostly Men”

Yale Medicine, 2015. https://medicine.yale.edu/news-article/11001/.

^[8] Young, Kate, Fisher, Jane and Kirkman, Maggie. “Do mad people get endo or does endo make you mad? Clinicians’ discursive constructions of Medicine and women with endometriosis,” Feminism and Psychology, 2018. https://journals.sagepub.com/doi/10.1177/0959353518815704.

^[9] Tavernise, Sabrina. “Drug agency recommends lower dose of sleep aids for women”, The New York Times, 2013 https://www.nytimes.com/2013/01/11/health/fda-requires-cuts-to-dosages-of-ambien-and-other-sleep-drugs.html.

^[10] Jackson, Gabrielle. “The female problem: how male bias in medical trials ruined women’s health,” Guardian, 2019. https://www.theguardian.com/lifeandstyle/2019/nov/13/the-female-problem-male-bias-in-medical-trials.

About the author

Manali Sarkar is a 2nd year MBSS student at MGM Medical College,Navi Mumbai. As a volunteer for MSAI, she had the opportunity to talk to various people (patient and healthcare professionals included) who would discuss such sensitive issues and the response among them would widely differ. Hence to highlight these varied responses and encourage a healthy debate among people of various nations, age, gender and race she has submitted this article to IFMSA