Gender biases and inequality in healthcare: Time to train the conscious doctors of the future

This article was exclusively written for The European Sting by Ms. Sadia Khalid, Junior researcher, and a PhD candidate at Tallinn University of Technology (TalTech), Estonia. She is affiliated with the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong strictly to the writers and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.

Gender-based violence continues to be one of the most notable human rights violations in the 21st century within all societies. It originates from deeply rooted societal gender inequality. Often these gender inequalities increase the risk of acts of violence by men against women. Gender-based violence has an enormous impact on individuals, sub-populations, and whole societies. This article discusses the way society structures and influences women’s lives has a significant impact on their health.

The issue of gender as a social determinant can contribute to gender inequities in health and access to health care. Gender norms and gender roles expectations together with other psychosocial factors greatly influence the perception and reporting of pain in medical practice which leads to disparities in treatments.

This inequality in healthcare, the under-treatment of chronic pain, causes a significant impact on one’s quality of life, general functioning, mental health, and employment status. Despite pain being a symptom in a wide range of medical conditions, in practice, it is regarded as subjective.
Pain scale measurements widely used in research and clinical practice are influenced by social factors, like gender.

Gender-related pain expectations and perceptions influence pain response and clinicians’ and researcher’s judgment. (1-3), Myers et al. suggest that from an early age boys and girls are taught along with gender norms how one should respond to pain. From a young age, the taught behavior and expectations from boys and men are to be tough, tolerate pain, and sustain painful experiences, while we see girls and women are socialized to be delicate, sensitive, careful, and to verbalize discomfort (4). Under these pretenses, one can be deduced that gender-related expectations about pain perception greatly influence pain responses.

Gender norms which can be held by patients, researchers, and clinicians are the main reason for the gender bias in healthcare today which manifests itself in form of disparities in treatment due to their demographics. (5-6) Data obtained from Quantitative & qualitative studies, review articles, and from theory-development articles on gender norms in pain treatment can be found in the medical, behavioral, and social sciences literature and Scientific literature has persistently shown the biological, (genetic and hormonal factors) difference among genders to depict the perception, description, and expression of the pain and show the benefit of Gender-specific treatments.

Gender norms for women experiencing pain are women being hysterical, sensitive, and inexplicably unfit in comparison to gender norms for men where they are viewed as stoic or tolerating pain (1) to appear ‘brave and manly’ Medically inexplicable pain as observed in Fibromyalgia is described as a challenge for research and clinical practice as it does not easily fit into the traditional bioscientific medical system (7) Literature suggests that pain does affect the identity and lifestyle in different ways in both men and women. In each societal construct, gender roles are relevant to patients in pain identity, lifestyle, and coping strategies.

Studies point out that Men’s Gender Identity is in Jeopardy due to chronic pain conditions which are predominant in women and perceived as feminine and view their suffering from pain as a threat to their sense of masculinity leading to shame, frustration and grief as it is a threat to gender norm “The strong body’ for men when they could not participate in physical activities to the same extent as before. (8) while the gender norm assigned to women in pain is “I have to learn women’s approach” where women are expected to accommodate the changing complex demands and simultaneously tries to manage pain and the demands of their surroundings. (9-10)

It is important to note that the concepts of hegemonic masculinity and andronormativity in health care, as a general driving force of gender constructions in Western societies.
Patriarchal society tends to reproduce itself through hegemonic masculinity.

Gender bias in the treatment of Pain faces a vicious circle where women feel mistrusted or psychologized by healthcare professionals causing significant distress. Concurrently, Pain, accompanied by distress, is typically attributed to psychological factors. If the patient vocalizes the distress, it can lead to an even greater degree of psychologization by healthcare professionals (11) Healthcare professionals not taking women’s pain seriously and this neglectful attitude became part of the problem [12-13]. In the 21st century, Women’s pain still struggles for legitimacy.

The need for awareness about gendered norms should be conveyed in medicine and scientific studies as researchers from different scientific backgrounds have found consistent demographic biases in pain perceived differently among genders which can influence the treatment decisions.

There is a need for evidence-based medicine practice among healthcare professionals in their daily work to improve the bedside manner as poor bedside manners do affect a patient’s emotional disposition and may discourage patients from seeking medical assistance altogether. Medical decisions should be based on current best evidence considering the impact of “gender-blindness’’ the excessive generalization of results to a greater population than studied.

Our great deal of scientific and medical knowledge is gathered from studies that didn’t consider biological sex differences or research mainly conducted in men” which is an impediment for gender equity in health care. According to the Sex, Gender and Pain Special Interest Group of the International Association for the Study of Pain (2007);

The increasing evidence for the sex differences in sensitivity to experimental pain and to analgesics and given that many clinical pain conditions are of greater prevalence in women than men, still females are understudied in animal and human study models and they suggested that “both genders” should be seriously taken into account in science and in medicine in order to understand their relative contribution to gender differences in pain response(p.27)(5).

Consensus report (2007) further stated that animal studies published in Pain over the preceding 10 years in at least 79% of them only male subjects were included, merely 8% of studies were based on the female subject, and another 4% explicitly designed to test for sex differences and the rest of the studies did not specify the gender differences. (14)

Due to a lack of sufficient knowledge and understanding about sex and gender-based research, patients and professionals both have been commonly neutralized.
Diagnostics and treatments originating from studies based on men are widely practiced as diagnostics and treatments protocol for all patients. Despite regulations stressing and dictating upon the inclusion of men and women in medical research, and the need for sex-specific studies, gender-blind attitudes can still be observed both in science and in medicine.

Hølge–Hazelton, and Malterud stated that “In Medical culture, a gender neutrality notion is still alive which suggests that gender issues are not relevant within this field” (p. 139) (15). Gender-blindness can lead to women’s needs being overlooked, as seen in coronary heart diseases (16), but can affect men’s needs as it leads to failure of diagnosis of certain conditions, as seen in under-diagnosed depression in men (17) A comparison of both biological sexes will enable us to further improve our understanding of individual differences in sensitivity to pain and analgesia,

The goal should be to raise the awareness to counteract gender bias in health care by sex-specific research and to support healthcare professionals, build their skills to prevent, treat and manage pain effectively based on to date gender-specific studies which in turn will provide more equitable care that is more capable to meet the need of all patients (5)

Footnote: All mentions of gender and sex are in reference to biological sexes and their differences.
the term “sex” refers to biologically based differences, while the term “gender” refers to socially based phenomena. Although considered that biological sex exhibits a major influence on one’s gender identity, sex and gender are not equivalent, and the terms are not interchangeable.
Conflict of interest:The author declared no conflict of interest.

References

1. Fillingim R. B., King C. D., Ribeiro-Dasilva M. C., Rahim-Williams B., Riley J. L. Sex, gender, and pain: a review of recent clinical and experimental findings. Journal of Pain. 2009;10(5):447–485. doi: 10.1016/j.jpain.2008.12.001.

2. Richardson J., Holdcroft A. Gender differences and pain medication. Women’s Health. 2009;5(1):1–12. doi: 10.2217/17455057.5.1.79.

3. Hoffmann D. E., Tarzian A. J. The girl who cried pain: a bias against women in the treatment of pain. Journal of Law, Medicine & Ethics. 2001;28(4):13–27. doi: 10.1111/j.1748-720x.2001.tb00037. x.

4. Myers C. D., Riley J. L., III, Robinson M. E. Psychosocial contributions to sex-correlated differences in pain. Clinical Journal of Pain. 2003;19(4):225–232. doi: 10.1097/00002508-200307000-00005.

5. Greenspan J. D., Craft R. M., Leresche L., et al. Studying sex and gender differences in pain and analgesia: a consensus report. Pain. 2007;132(1): S26–S45. doi: 10.1016/j.pain.2007.10.014.

6.Krieger N. Genders, sexes, and health: what are the connections—and why does it matter? International Journal of Epidemiolog

7.Bernardes S. F., Keogh E., Lima M. L. Bridging the gap between pain and gender research: a selective literature review. European Journal of Pain. 2008;12(4):427–440. doi: 10.1016/j.ejpain.2007.08.007. 

8. Clarke L. H., Bennett E. ‘You learn to live with all the things that are wrong with you’: gender and the experience of multiple chronic conditions in later life. Ageing and Society. 2013;33(2):342–360. doi: 10.1017/s0144686x11001243.

9. Dao T. T., Leresche L. Gender differences in pain. Journal of Orofacial Pain. 2000;14(3):169–184.

10. Côté D., Coutu M.-F. A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation? Disability and Rehabilitation. 2009;32(2):87–102. doi: 10.3109/09638280903026572.

11. Tait R. C., Chibnall J. T., Kalauokalani D. Provider judgments of patients in pain: seeking symptom certainty. Pain Medicine. 2009;10(1):11–34. doi: 10.1111/j.1526-4637.2008. 00527.x

12. Werner A., Isaksen L. W., Malterud K. ‘I am not the kind of woman who complains of everything’: illness stories on self and shame in women with chronic pain. Social Science & Medicine. 2004;59(5):1035–1045. doi: 10.1016/j.socscimed.2003.12.001

13. Lillrank A. Back pain and the resolution of diagnostic uncertainty in illness narratives. Social Science & Medicine. 2003;57(6):1045–1054. doi: 10.1016/s0277-9536(02)00479-3. 

14. Mogil JS, Chanda ML. The case for the inclusion of female subjects in basic science studies of pain. Pain. 2005; 117:1–5.

15. Hølge-Hazelton B., Malterud K. Gender in medicine—does it matter? Scandinavian Journal of Public Health. 2009;37(2):139–145. doi: 10.1177/1403494808100271.

16. Johnston N., Bornefalk-Hermansson A., Schenck-Gustafsson K.et al. Do clinical factors explain persistent sex disparities in the use of acute reperfusion therapy in STEMI in Sweden and Canada? European Heart Journal: Acute Cardiovascular Care. 2013;2(4):350–358. doi: 10.1177/2048872613496940.

17.Möller-Leimkühler A. M. Barriers to help-seeking by men: a review of sociocultural and clinical literature with reference to depression. Journal of Affective Disorders. 2002;71(1):1–9. doi: 10.1016/s0165-0327(01)00379-2.

About the author

Sadia Khalid, Junior researcher, and a PhD candidate at Tallinn University of Technology (TalTech), Estonia. She has been working on her research project “The role of Helicobacter pylori intestinal microbiota in the development of liver diseases” under supervision of Dr. Pirjo Spuul at Faculty of Science, Institute of Chemistry and Biotechnology.,TalTech. Previously, she has worked as a research specialist in biomedicine and translational medicine department in the university of Tartu, Estonia. She obtained her MD in emergency medicine in 2017 from the Dalian Medical university, China and MBChB in 2013 from the Weifang Medical university, China. Her current research interests include infectious diseases, bacteriology, hepatology, and gastroenterology.