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.
The Sex Bias Myth in Medicine
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. I 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
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, smokinggun
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 198 1, were quite different from those of the San
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. Coronaryartery 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
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 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 infon-nation now
available was reconstructed retroactively to 1981. Nevertheless, these
early data provide a window on spending pattems 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
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 22,07 1), 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 Joumal of the American
Medical Association in July of 199 1, and were generally ignored by
the nonmedical press.
Most studies on the
prevention of "premature" (occur-ring 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 I 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 I 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 concem,
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.
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'shealth
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
THE ATLANTIC MONTHLY. AUGUST 1994