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THE MYTH OF GENDER BIAS IN MEDICINE
by Cathy Young ©, Womens Freedom Network
with Sally Satel ©, Yale Medical School
For too long, health care, health research has been addressed from one point of view, the white male point of view.
When it comes to health care research and delivery, women can no longer be treated as second-class citizens.
Americans health care system traditionally hasn't treated women equally or fairly
I've had a theory that you fund what you fear. When you have a male-dominated group of researchers, they are more worried about prostate cancer than breast cancer. Women have had their particular concerns grossly underfunded& Breast cancer is perhaps the most obvious, the most painful, the most sweeping [example].
MYTH & FACT There may be no better example of gender bias in the annuals of medicine than the neglect of STD's (sexually Transmitted diseases) in women.
Articles Dealing With Sexually Transmitted Diseases Listed on the Medline Index
Women as Proportion of all Subjects of Drugs Approved in 1988
FDA surveys conducted in 1983 and 1988 found that ... both sexes had substantial representation in clinical trials conducted before FDA approval of drugs,in proportions that usually reflected the prevalence of the disease in the sex and age group included in the trials.
Detecting Sex Differences in Medical Research One criticism often made by women's health advocates is that even when women are included in clinical trials, it is in numbers insufficient to detect differences in the way women and men respond to medications. At issue is the generalizability of findings. In other words, if studies lump men and women together in assessing the effect of a medication on, say, blood cholesterol, it can be hard to know if the drug worked less well in women (or men for that matter). In an ambitious effort to clarify questions like these, both the FDA and the NIH now require that adequate numbers of women be included in trials to conduct what is called a subgroup gender analysis. The problem is that this kind of statistical analysis requires a bigger total sampleand a more costly studythan simply assessing the degree of effectiveness in men or women. What's more, the expense may not always be justified since men and women tend to respond comparably to most (though by no means all) medications. Clinical reality, then, calls for selectivity in including women (and men) rather than the inclusion-for- Indeed, doctors have been successfully extrapolating from women to men in the treatment of a number of conditions such as osteoporosis, rheumatoid arthritis. breast cancer, and eating disorders. The recent report in the journal Circulation, which warned about the cardiac risks of second hand smoke, was based on data from an all-female sample, the Nurses Health Study. On careful reading, the studys conclusions don't stand up -- the design was too weak to show a cause and effect relationship -- but the key point here is that neither the Harvard researchers who conducted the study nor anyone else expressed caution in extrapolating to men the risk of second hand smoke exposure. "The question is not, Do differences exist? It's, are they important enough to merit the hunt?" says Curtis Meinert, an epidemiologist who directs the Johns Hopkins University Center for Clinical Trials. This is not to say that meaningful gender differences don't occur. Hormonal fluctuations of the menstrual cycle and menopause, for example, may have important implications for women receiving medications. Epidemiologist Janet Holbrook of Johns Hopkins University, intrigued by the increasing emphasis on finding gender differences in treatment response, examined published reports of multi-center clinical trials between the years 1990 - 1994. All were large enough to include both men and women in adequate numbers to detect a difference if it existed (of note, 78% of trials in her sample studied both genders, 18% of trials were female-only and 4% male-only.) Among the two-gender studies that showed a treatment effect, Holbrook found no subgroup differences based on sex. Thus, when Phyllis Greenberger, executive director of the Society for Advancement of womens health, says disingeniously: "As with the designers of automobile airbags, the model for the medical profession was a middle-aged, middle-weight man" one has to remember two things. One: where women are predominantly afflicted, they are always the most intensively studied. Said acollege of mine who studies depression and bulimia: "Researchers are too opportunistic not to study the people that come right into their clinic:in my case thats women." This is consistent with the work of Dr. Chloe Bird of the New England Medicine Center, Harvard School of Public Health. She surveyed all clinical trials published in JAMA in 1990 and 1992 and found that 51% of studies had one-third or fewer women. The male-only studies tended to be those conducted in Veterans Affairs Hospitals, armed services or prisons or those concerned with male-specific diseases. Second: airbags save women loo, in other words, many times it doesn't matter that a medication was tested primarily in one sex. In many cases the physiologic differences between men and women don't translate into meaningful clinical effects. Leslie Z. Benet, Chairman of the Department of Pharmacy at the University of California, San Francisco writes, "'Will differences in drug response due to gender be clinically significant? My answer is, rarely if ever."' Dr. Benet bases his negative response on two observations. First, physicians tailor the medication dose to the patient; sometimes this is a function of body mass and kidney function, other timesas when medicating for mania or psychosis we base dose on intensity of symptoms and then lower the dose if side effects are too uncomfortable for the patient. Either way, patients generally end up on an individualized, empirical dosing schedule that doesn't rely on a set formula derived from gender-comparion research. In the case of drugs that are therapeutic at one dose but toxic at a slightly sigher dose (narrow therapeutic index) meticulous personalized dosing can be lifesaving. Second, according to Dr. Benet, in situations where there is a large discrepancy between positive effect and toxicity (broad index) "the variability in the male population most likely already encompasses the difference between the male and female population." |
It has become an axiom that for years a male-dominated medical establishment has neglected women's needs -- giving comparatively little attention to research on female-specific diseases such as breast cancer, systematically excluding women from clinical and from drug testing, and providing less than equal care to female patients. These charges have been made by politicians from both parties, and particularly by Congresswomen such as now-retired Rep. Patricia Schroeder (D-Co.), Rep. Constance Morelia (R-Md.), and Sen. Olympia Snowe (R-Maine). They have also been repeated in the media, particularly in women's magazines. Despite a few challenges to these claims, such as an article by Dr. Andrew Kadar in The Atlantic Monthly in August 1994, both the general public and the majority of commentators continue to accept them at face value. Gender bias in medicine has become a powerful symbol for the general mistreatment of women by patriarchal society.
But what are the facts behind the rhetoric? 1. Clinical Research While women's health care amounts to two-thirds of the nation's annual medical bill, medical research has mainly been done on men, for the benefit of men only. In 1997, during the controversy over the preventive benefits of early mammography, Sen. Olympia Snowe (R-ME) noted that she had "led the charge to put an end to clinical trials conducted entirely on men." It has become a virtual article of faith that until the recent wave of women's health activism. women were systematically excluded from clinical trials. But these claims are based on slim evidence at best. According to a 1993 report by the Institute of Medicine of the National Academy of Sciences, "The literature is inconclusive about whether women have been excluded from or importantly underrepresented in clinical trials.'' And in a memo to the National Academy of Sciences, NIH reported that in 1979, of the 293 clinical trials, 268 involved both genders. Of the remainder, 13 were limited to women, 12 to men. Even Judith LaRosa and Vivian Pinn, administrators at the National Institutes of Health Office of Research of Women's Health-an office whose existence largely depends on claims of gender inequities in need of redress-concede, in a 1993 article, that ''[t]he extent of women's exclusion from clinical trials has not been well documented "and that some of the exclusions were sound." Drs. LaRosa and Pinn sum up, "The exclusion of some women from clinical studies may sometimes be valid, but not all women all the time." However, as their own article suggests, it is simply not true that all women, all the time have been excluded from clinical studies. In another article, Dr. Pinn writes, citing a 1989 General Accounting Office Report, that women were not systematically excluded from studies," though "they were not systematically included"; that is, in many cases, no special effort was made to ensure that a trial had enough women to make meaningful conclusions about possible sex differences.8 Some important studies have been limited to male participants. A trial which studied the benefits of aspirin for heart disease prevention in a sample of over 22,000 male doctors has often been cited as the ultimate example of male bias in medicine This study has been sometimes used, inaccurately, to imply that the preventive role of aspirin has been studied only in men. In fact, when its preliminary results were made public in 1988, a study of the effects of aspirin on heart attacks in women had been underway for three years, with 87,000 female nurses as subjects. The nurses' study was less rigorous: while the doctors' study was a randomized, double-blind test in which half the subjects were given an aspirin every day and the other half received a placebo, the nurses reported their own aspirin intake in three surveys over six years. However, the researchers in the nurses' study made an adjustment for other risk factors when comparing the women's medical histories, and concluded that aspirin helps prevent heart attacks for women as well as men. An investigation by the institute of Medicine found that in addition to the aspirin study, were three other all-male studies on heart disease, analyzing the risk factors for heart disease and the effectiveness of cholesterol-lowering drugs. Were these studies sexist? In fact, a number of respected medical researchers-such as Dr. Lynn Rosenberg, a Boston university epidemiologist who has done extensive research on women's health-believe that focusing on males first, and then deciding whether the results could be applied to women or whether additional studies on women were needed, was scientifically justified." Even Drs. LaRosa and Pinn of the Office of Research on Women's Health concede that "compelling factors" have limited the inclusion of women in these studies. Paradoxically, one of the main reasons for this is the female advantage in avoiding coronary heart disease in middle age. A study of the effectiveness of heart attack prevention requires a group which would normally have a relatively high rate of heart attacks. Before 65, heart attacks kill men three times as often as women; between 65 and 74, the ratio is two to one. An equally reliable aspirin study in women would have needed at least twice as many subjects, greatly increasing the cost of the study. Thus, the Lipid Research Clinics Coronary Primary Prevention Trial which investigated the preventive effects of a low-fat diet-and which was conducted within a larger, two sex study of cholesterol and heart disease, the Lipid Research Clinics Program-was limited to men with high cholesterol in order to reduce the sample to "a feasible level." Far from taking women's exclusion for granted, the researchers felt obliged to explain that "women were not recruited because of their lower risk " Major observational studies of heart disease such as the Lipid Research Clinics Program have included women. The longest and largest of these, the Framingham Heart Study, was launched in 1948 with equal numbers of women and men; by the early 1990s, 60 percent of the participants were women.'' (However, in a 1970s study of the offspring of the original Framingham subjects, the influence of such factors as alcohol use, weight and cholesterol levels on severe coronary heart disease was analyzed for men only-not because of sexism but because there were too few cases of severe heart disease among women for such an analysis. The clinical trial which uses randomly assigned treatment groups and control groups is considered the gold standard" of medical research. However, observational or surveillance studies such as the LRCP, the Framingham Heart Study, and the Nurses' Health Study have provided a wealth of data on coronary heart disease in women, including its relationship to estrogen replacement therapy, smoking, aspirin use, and oral contraceptives. Nor is it true that a "male model" was mindlessly applied to women. Both sexes were typically included in studies of heart functioning in healthy subjects; sex differences in outcomes of surgery and drug therapy for heart attack patients were investigated back in the 1970s and early '805. Overall, more than half of clinical trials of heart disease treatments have included women in percentages fairly close to their proportion among heart disease patients under 65.'' And elderly patients of either sex have rarely participated in drug trials because of frailty and coexisting illnesses. It is also worth noting that the increased visibility of heart disease in women predated the rise of a politicized women's heath movement. It was probably due to the fact that people were living longer and more evidence of older women's vulnerability to heart disease became available. Arguments for better representation of women in cardiovascular research may well have some validity, even if factors other than sexism account for their inadequate representation. This does not mean, however, that heart disease research has benefited primarily men. In 1970-79, men and women experienced similar declines in mortality from head disease. It is true that between 1979 and 1993, the progress for men was more significant: men's age-adjusted rates of heart disease mortality fell by 30%, compared to 23X for women. However, it is important to remember that men started from a much higher base. It is also likely that the discrepancy reflects primarily the effects of rising rates of smoking among women. Undoubtedly, in some areas, there have been gaps in research related to women's health. One such area is AIDS. Dr. David Gremillion, director of internal medicine at the Wake Medical institute in Raleigh, North Carolina, who has done research on patients with HIV, agrees that women with AIDS weren't studied enough in the eighties and that too little attention was paid to such issues as gynecological problems and child care-though he believes that this was due less to gender bias than to pressure from activists who wanted to keep the focus on AIDS as a gay male diseased. Of course, it is important to remember that in the early years of the epidemic, women made up a minuscule proportion of those afflicted. In 1993, women accounted for 9 percent of the total enrollment in the U.S. AIDS Clinical Trial Group; while low, this number was not very different from the proportion of women among reported cases of AIDS (11 percent). There is even less evidence of women's "exclusion" from studies on other diseases. Stroke, which affects men about 20 percent more often, has been well-researched in both sexes: of nearly 6,000 human studies in English-language journals listed in the Medline database, close to 90 percent include women. Women have comprised at least a third of the subjects in major studies of the effects of aspirin and other drugs on stroke patients and of the effectiveness of carotid endarterectomy (surgery in which fatty deposits are removed from the Walls of the carotid artery to prevent stroke). Moreover, gender differences in the patterns of stroke have been extensively investigated. The first large randomized trial of treatment for moderate hypertension in the late 1960s, conducted in cooperation with the Veterans Administration, was all-male. But as early as 1970, the National Heart, Lung and Blood institute (NHLBI) recommended a large-scale study that would "include both sexes [and] all races." 26 Subsequent clinical research on hypertension, starting with the Hypertension Detection and Follow-up Program (HDFP) in which 159,000 people were screened and 8,000 admitted into the study, has included large numbers of women. Women's Inclusion in Hypertension Research
Nor were women ever left out of cancer research. Indeed, they outnumbered men by 2,000 in a study of body iron levels and cancer risk based on the 1971-74 National Health and Nutrition Examination survey. In Outrageous Practices: The Alarming Truth About How Medicine Mistreats Women ( 1994), authors Leslie Laurence and Beth Weinhouse cite as an example of bias the fact that in 1989, women made up 44 percent of subjects in studies of colorectal cancer at the National Cancer Institute although "51 percent of colorectal cancers occur in women." However, a six-point gap would probably not strike most people as an outrage. In some areas of clinical research affecting both sexes, medical literature is more likely to focus on women than on men. Thus, a Medline search shows that 10 percent of all articles published on studies of diabetes and kidney disease deal with data on men only, and 15 percent with data on women only. here are even more dramatic imbalances: fewer than 10 percent of medical journal entries on chemotherapy in 1966-1990 dealt only with men while a full 30 percent dealt only with women. What about the charge that nearly all drug testing has been done exclusively on men? It is true that Food and Drug Administration guidelines written in 1977 explicitly barred women of Childbearing potential," defined broadly to cover all women of childbearing age, from early stages of drug testing (with an exception for life-threatening illnesses). The policy, changed in 1993, was instituted in the wake of publicity over vaginal cancer in women whose mothers had used DES while pregnant. While the ban was probably overbroad, it is important to remember that it applied only to the earliest stages of drug trials. Phase I of drug trials consists of basic safety testing in less than 100 volunteers; Phase 2 involves testing for efficacy and side effects in 100 to 300 patients; Phase 3, long-term monitoring in 1,000 to 3,000 people. Even before recent policy changes mandating the inclusion of women in the earlier stages of testing, women participated in the later stages of Phase 2 and in Phase 3. (Some feminists have charged that even animal testing of new drugs is done almost exclusively in males. In fact, all such testing has included studies of the effects of drugs on gonadal functions and reproductive cycles in male and female rats, as well as studies of fetal malformations in pregnant rodents.) The same guidelines that excluded fertile women from early tests stated that prior to approval, drugs had to be studied in the population groups for whose consumption they were intended. Figures provided by Dr. Ruth Merkatz, special assistant to the FDA commissioner for women's health, show that women were well-represented in clinical studies of drugs when the entire duration of these studies is considered: At a 1993 conference on women and minorities in clinical research, pharmaceutical executive Dr. Janice Bush agreed that early detection of sex differences in drug trials could help "better selection of doses [and] better labeling information." While the FDA recommended in 1988 that responses to drugs be analyzed by sex, age, and race, a review of 1988-1991 trials found that this was only being done about half the time. However, it is not simply a matter of negligence. Trials consistently large enough for valid comparisons would cause research costs to explode. What is needed, most experts agree, is not an across-the-board quota but a measured approach to identify cases where sex differences are "clinically meaningful." Such cases are more the exception than the rule. 2. Women's Diseases There is a widespread perception that breast cancer has been "shortchanged" because it is a woman's disease. But in a 1993 article, Mary Lou Wright, head of the Mathews Foundation for Prostate Cancer Research, argued that men are the ones appallingly neglected." That year, Congress had appropriated $39 million for research on prostate cancer and $400 million ($208 million from the NIH and $210 million from the Department of Defense) for breast cancer. For 1994, National Cancer institute funding for breast cancer research was boosted to nearly $300 million; prostate cancer spending was raised to $55 million. (In 1996, prostate cancer killed about 41,000 men and breast cancer killed about 44,000 women ) Women's health advocates argue that higher spending on breast cancer in recent years is a corrective measure. According to Rep. Nita Lowey (D-NY), "Breast cancer has been drastically underfunded for far too long, and because of past neglect we are playing catch-up." In fact, while breast cancer activism did not become a political force until 1991. Yet throughout the 1980s, annual NCI funding for breast cancer studies was more than four times the amount for prostate cancer research; from 1981 to 1991, a total of $658 million went to breast cancer and $113 million to prostate cancer. It is revealing that when the NCI held a consensus conference on prostate cancer in 1987, it was hampered by the relative shortage of research data. One panelist remarked, "We are not dealing with a situation comparable to node-positive breast cancer where there are a host of randomized studies." What about other diseases that affect primarily women? A 1993 ABC News report cited osteoporosis, "a bone disease that cripples mostly older women ... so common it's often ignored and research into it is under-funded." But in fact, osteoporosis is extensively covered in medical literature, with over 8,000 Medline references since 1966. From 1978 to 1988, the three leading medical journals (The New England Journal of Medicine, The Journal of the American Medical Association, and Annals of Internal Medicine) ran a total of 116 items on osteoporosis and 93 dealing with diseases of the prostate. In the 1970s and '80s, a great deal of research was carried out, often under the auspices of the NIH, on the effects of estrogen, calcium, and fluoride on bone loss in older women. Some claims made about the alleged neglect of women's health are downright bizarre. In Outrageous Practices, Laurence and Weinhouse write that endometriosis, a condition in which uterine tissue grows inside the abdominal cavity, causing not only severe pain but in many cases sterility, was not only ignored by medical researchers but was not considered real well into the 1980s: In fact, over 4,000 articles on this "non-existent" ailment appeared in English-language medical journals from 1970 to 1990. In the 1970s, treatment of endometriosis with hormonal drugs was being tested in clinical trials in the U.S. and Europe. ( The FDA approved danazol for the treatment of endometriosis in 1977.) Throughout the '80s, articles on drug and surgical treatment for this disease appeared regularly in medical literature from the American Journal of Obstetrics and Gynecology to the New England Journal of Medicine. In the early 1990s, there was an outcry over a report that, according to a government study, women's health projects accounted for less than 14 percent of NIH spending in 1987. This alleged inequity was cited by Congresswomen in the effort to pass legislation requiring more spending on women's medical needs and establishing a federal Office of Women's Health.53 What was rarely mentioned was that NIH spending on male-specific health projects accounted for just under 7 percent of its total budget, less than half the amount for women. 80 percent of the money went to projects that benefited both sexes. 3. Unequal Treatment? In addition to claims that women have been neglected in medical research, women's health activists also charge that women have received second-class health care. Female heart patients, in particular, are said to be shortchanged, as the headlines suggest: WOMEN LOSE OUT ON HEART TREATMENTS (USA Today) STUDIES SAY WOMEN FAIL TO RECEIVE EQUAL TREATMENT FOR HEART DISEASE (New York Times) WOMEN AND HEART DISEASE: BIAS EXISTS IN DIAGNOSIS OF AILMENTS (Denver Post) It is a known fact that female heart attack survivors tend to fare worse than their male counterparts. In one study by Dr. Richard Becker of the University of Massachusetts, nine percent of women and four percent of men lived less than six weeks after a heart attack; 12 percent of women and six percent of men died within a year. While age differences-a quarter of the women were over 70, compared to nine percent of the men-and coexisting illnesses did not fully account for this gap, it could not be attributed to "bias": the men and women had received similar care, including clot-busting drugs early in the attack. There is no question that women receive aggressive, high-tech testing and treatments such as coronary bypass grafts (CABG) and coronary angioplasty (PTCA), in which a clogged artery is opened with a baloon-tipped catheter, less often than mends But is this "bias"? According to Dr. Daniel Mark of Duke University, "When you just compare men and women, it's apples and oranges." His own review of over 400 cases from the early 1980s was one of several to find that when women are similar to men in age, physical condition, and severity of disease, the treatment they receive is quite similar. Subsequent tests showed that cardiologists had erred on the side of overestimating the chances that a woman had severe heart diseased other research has yielded similar results A review of a random sample of 2,739 men and 1,240 women who underwent cardiovascular procedures in thirty hospitals in New York State in 1990 showed that 46 percent of the women undergoing coronary angiography had no or insignificant disease, compared to only 26 percent of the men. These findings suggest that physicians appropriately apply knowledge about the association of gender, risk factors, and coronary artery disease prevalence.... In summary, we have found no evidence of gender bias in the appropriateness of the use of coronary angiography, coronary artery bypass surgery, or PTCA Several studies have also noted that, as Dr. Nina Bickell of Gouverneur Hospital in New York has written, "the effect of gender on treatment selection may have led to more appropriate treatment of women," since men with relatively low risk ... and little to gain from surgery were more often referred for surgery." An analysis of 1988 records from two Michigan hospitals published in The Journal of Family Practice found that at one of them, men with low probability of serious ill-ness were admitted to the cardiac unit at a rate 50 percent higher than low-risk women. (At the other hospital, there were no sex differences.) This high rate of admission, the authors concluded, "certainly seems to represent unnecessary hospitalization" and to reflect overtreatment of men rather than undertreatment of women." Bias, in the epidemiologic sense, was certainly demonstrated in hospital A's admission pattern. However, since bias is a term that also carries connotations of unfairness, perhaps even denial of needed care, bias in that sense was not demonstrated here (unless lack of unnecessary hospitalization is considered unfair.) Aggressive treatments may also be less appropriate for women because of safety concerns. Studies in the 1970s and 1980s found that women's risk of dying after angioplasty, while small (26 in 1,000), was nine times higher than men's (3 in 1,000). Even with adjustments for age and severity of disease, women died four times as often. To some, women's higher mortality rates are further proof of bias: surgeons trained on male bodies are less adept at operating on females; women's arteries rupture more during angioplasty because the balloon tips, designed by and for men, are too large; women are referred for surgery too late because their symptoms aren't taken seriously The latter charge is disputed by 1985-86 data from the National Heart, Lung, and Blood institute registry; if anything, concluded two cardiologists who reviewed the records, "the opposite appears to be true." One of the researchers, Dr. Hiltrud Mueller of New York's Montefiore Medical Center, also disputes charges that the problem is due to balloons being designed for male-sized arteries, since there are different balloon sizes and since there are male patients who are of small stature and therefore have smaller coronary arteries. Body surface, not gender, best predicts how a patient will fare during and after heart surgery. Of course, body surface is correlated with gender. but the miniaturization of medical devices is a real problem that has to do with technical complexity, not gender. In the hands of advocates and the media these complexities are often turned into a simple case of gender bias. Studies that purport to find a pro-male bias are often given more prominence. Even an article which acknowledges that "less care" for women does not necessarily mean worse care often runs under a headline like "Studies Say women Fail to Receive Equal Treatment for Heart Disease." Of course, women's health advocates are right to criticize the tendency to think of cardiovascular disease as a man's problem. This attitude can cause potentially dangerous symptoms to be overlooked, not only by doctors but by women themselves. Clinical judgments which take into account women's lower statistical risk are hardly "sexist"; but physicians and patients should be aware of factors that may elevate an individual woman's risk. Is there other evidence that doctors treat men and women differently, and that women are treated worse? In the late 1970s, physicians who were asked to evaluate simulated cases saw female patients as somewhat more likely to make excessive demands-which may be due to women's real tendency to voice more complaints and ask more questions than men during a typical visit-and to have emotionally influenced or even psychosomatic problems.67 Even so, gender was not the sole factor (patients of either sex who mentioned a personal problem were more often seen as demanding, emotional, and prone to imaginary ailments), and doctors were by no means hesitant to make patronizing judgments about men. Contrary to the stereotype, they also suggested tranquilizers for men and women patients with equal frequency. A 1979 review of the charts of 52 married couples found that doctors tended to order more comprehensive tests for men with common complaints; another study seven years later failed to replicate this result. The largest investigation of gender and quality of health care, based on a 1975 national survey, concluded not only that men and women generally received similar treatment but that when a difference existed, women were more likely to be referred for tests, given prescriptions, and asked to return for a follow-up Visited These findings may not prove bias against men; as the researchers noted, women may get more care because they ask for more care (they also see doctors nearly 50 percent more often than men) or seem more distressed by their condition. But they certainly don't show bias against women. Conclusion There is no doubt that historically, women in our society have suffered many forms of discrimination. There is also little doubt that in the 19th century, many and perhaps even most male physicians held condescending and sexist views of women as frail, sickly, hysterical creatures ruled by their wombs (beliefs that were no more sexist than prevailing cultural attitudes at the time). But as far back as 1937, a male physician wrote that "while these sentiments may have had some standing in the past, they are no longer the fashion of today"; hailing a new ideal of robust womanhood, he urged women to become active in sports and "say farewell to the 'interesting invalid." It is true that even more recently, cultural stereotypes about gender may have led to some blind spots in medical knowledge. Research in sports medicine, for instance, has focused very heavily on males. The same has been true of research on alcoholism-a subject on which, as recently as 1994, 59 male-only studies and just eight female-only studies were published (as well as 145 studies dealing with both sexes). Though alcoholism is more common in men, the research emphasis on males seems disproportionate. However, it was certainly never true that "male medicine" did not care about women's health and well-being. Even men who hold the most sexist views of women have always cared about the health of their wives, daughters, sisters, and mothers. Medics are certainly no exception. It is also absurd to overlook the many ways in which modern medicine has benefited women. For most of human history, men on average lived slightly longer than women. Today, American women outlive men by an average of seven years. This is because medicine has eliminated most of the risk of death from complications of childbirth and has largely vanquished the infectious diseases- smallpox, cholera, tuberculosis-that once killed large numbers of men and women alike at a relatively young age. As Dr. Andrew Kadar of the UCLA School of Medicine points out, "The elimination of infection as the dominant cause of death has boosted the prominence of diseases that selectively afflict men earlier in life." 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. In recent years, the changes in women's roles in society have transformed the relationship between women and medicine. Women have become more assertive and better-informed patients. And there are unprecedented numbers of women in the medical profession, as practicing physicians and as researchers. Today, women make up close to half of the nation's medical students, reaching 50% at some top medical schools. Nevertheless, some women's health advocates continue to push a divisive agenda that pits women against men. Dr. Sharyn Lenhart, chair of the American Medical Women's Association's Gender Equity Committee, has expressed the view that real "change in deeply ingrained behaviors in medicine would take no less than a 3:1 ratio of women to men in the professions in Outrageous practices, Laurence and Weinhouse decry sexism in "coed" substance abuse treatment programs but concede that women in these programs do at least as well as men. Their response is to quote a researcher who says, [I]f women are doing that well in nongender-specific programs, might they not do even better in more specialized programs?" With such attitudes, it is likely that claims of gender bias will persist whether or not they have any basis in reality. Unfortunately, these claims produce baseless anger and resentment in many women. They also create a climate in which men's health can be "short-changed" in some ways-for example, when special funds are directed to women's health on the mistaken assumption that women's health has been historically neglected. Thus, in 1996, the Department of Health and Human Services announced the establishment of six National Centers of Excellence in Women's Health, a public-private partnership partially funded by the U.S. Public Health Service's Office on Women's Health. There are other state-level initiatives, such as a 1994 bill in Minnesota establishing a women's health center. (The bill's statement of purpose asserted that "[I]n the United States and in Minnesota, a disparate amount of health policy and research attention has been directed to males.") In the meantime, no similar initiatives are undertaken for men. However, the politicization of women's health has not always been good for women. The rhetoric about "male medicine" may push a woman to avoid "politically incorrect" procedures which may be medically beneficial, from "medicalized" childbirth to hysterectomy. A New Jersey woman, Ellen Bertone, wrote in a letter to the New York Times about her experience with a hysterectomy counseling group: I postponed [a hysterectomy] for several years because I had been made to fear it and its consequences, to feel that I was submitting to manipulation by the patriarchal medical profession, and that I was somehow failing if I gave in and had the surgery. I later regretted delaying the surgery because of the dramatic improvement it made in the quality of my life. I had suffered needlessly for several years. There is little doubt that the political backlash against the NCI's stance was prompted at least in part by the belief that the uncertainty over mammograms reflected neglect of women. In a Washington Post op-ed article responding to Matthews's critique, Sen. Olympia Snowe (R- Maine), author of the resolution on mammography, defended the Senate's intervention in medical policy by asserting, "After all, it was my female congressional colleagues and I who led the charge to put an end to clinical trials conducted entirely on men." Many in the media took a similar approach. On the CNBC show Equal Time, co-host Dee Dee Myers asked, "If this was a health problem unique to men, would more money have been spent trying to figure out how to detect it and what to do about it?" In fact, just a month later, there was news of a parallel dilemma for men: the American College of Physicians, departing from standard guidelines, advised against routine prostate cancer testing for all men over forty. But this news generated little media attention and no political response. Interestingly, some women's health advocates are beginning to say that legislators' enthusiasm for making medical decisions when it comes to women's health may be a mixed blessing. Cindy Pearson, executive director of the National Women's Health Network, has said that this legal intervention is a "double-edged sword" and results in measures whose health benefits "are often arguable." Other advocates see paternalism in all the special attention paid to women's health-which is ironic in view of the fact that they have been clamoring for such attention. In other ways, too, the politicization of women's health may produce bad science. In 1991, with Dr. Bernadine Healy at the helm, the NIH launched the Women's Health Initiative, one of its largest-ever clinical trials. Two years later, a committee appointed by the National Academy of Sciences to review the WHI at the request of Congress due to cost overruns issued a scathing report. Not only had the cost estimates been grossly unrealistic but, according to the panel, the study was too poorly designed to yield valid results and the participants had not been adequately informed of possible risks. This report prompted Barbara Culliton, a medical journalist for Noture magazine, to ask, "How can NIH, widely regarded as the fountainhead of the good design of trials and experiments, have perpetrated such a faulty design as that of WHI?" The IOM committee recommended an overhaul of the WHI, suggesting that much of the data the study was intended to obtain could be obtained from scaled-down, better-focused, less expensive projects. The response, once again, was political. Dr. Healy complained, "Billions of dollars have been spent to do research in men, and now a relatively modest study comes along to do studies in women, and it is subject to this kind of scrutiny." Rep. Patricia Schroeder told the press that since the WHI was meant to address "a historical lack of interest in women's health issues," scaling it down "would repeat past inequities." The advice of the panel (which consisted of seven women and four men) was largely ignored. The myth of anti-female bias in medicine been perpetuated by politicians in Congress, by public figures including HHS Secretary Donna Shalala, by the Office of Research on women's Health, and by many in the media. Many of those responsible for this myth are undoubtedly well-intentioned and motivated by the sincere belief that women have been shortchanged by the medical establishment. But this is not just a case of "noble lies" in the service of a good cause. The gender-bias myth does not truly help women but merely causes them unnecessary alarm. Often, it promotes bad science. Nearly always, it promotes bad politics: gender antagonism implicit in the charge that men do not care about women's health, and paternalism implicit in the notion that women's health problems deserve special attention. It is time to retire the myth and focus our energy on the best ways to provide health care for everyone. This article is reprinted with the permission of Cathy Young and the Women's Freedom Network.
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