One of the most striking findings from the front lines of the coronavirus pandemic is that more men are dying from the virus than women. According to the New York City Department of Health, the most recent statistics show that men make up roughly 60 percent of total deaths in New York, the epicenter of the pandemic in the United States. But most doctors and researchers don’t yet understand how the virus behaves in men compared to women—information that could help explain the difference in fatality rates and that could inform the best course of action for all patients. For now, doctors are left to treat patients with one-size-fits-all treatments.
To Alyson McGregor, MD, an associate professor of emergency medicine at the Warren Alpert Medical School of Brown University, this is a major problem. But it’s also not surprising.
Doctors make a promise to act in their patients’ best interests. Yet, in some instances, they may be unknowingly hurting half of the population because modern medicine is based on an outdated model that dismisses the biological differences between men and women. “If we do not determine how this virus affects men and women differently, then we will potentially miss key elements regarding prevention, treatments, drug efficacy, and survival,” McGregor says.
The way the health care system has handled the pandemic is just the latest manifestation of the dangers of routinely ignoring sex-based biological factors. In her new book, Sex Matters: How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It, out this month, McGregor unveils how this blind spot has given rise to implicit biases that underlie the U.S. medical system. While men are more adversely affected in the case of COVID-19, it’s an exception to the rule. Women are regularly misdiagnosed and underserved by the medical world, and the pandemic highlights how overlooking gender and sex differences can negatively impact everyone.
The way we treat cardiovascular diseases shows how a biased system can be harmful to women. Stroke shows up in unique ways in women: instead of suddenly losing function on one side of the body (as is common in men), women may have a migraine-like headache or a sudden change in their mental or emotional state when experiencing a stroke. These nontraditional symptoms can mean women and their health care providers take longer to realize something is wrong, delaying care. When women are treated, they are less likely to receive the appropriate diagnostic tests or medication in a timely manner.
The fact that most scientific research is conducted on men isn’t a secret. But scientific research doesn’t just live in academic journals. The findings underpin the diagnostic and clinical care plans physicians use to treat real people. “The whole medical care system is trained to look for patterns of disease. But because those patterns are based on years and years of research on men, when you go see your doctor or come to the emergency department, a lot of times disease states aren’t recognized in women,” McGregor says. It leaves doctors handicapped when trying to provide the best care.
When McGregor first figured out that women are excluded from medical studies, she was shocked. “There’s an assumption that research is done in a fair and balanced way. That’s what we learn in medical school. But they never told us who the research was done on. That evidence was just brought into medical schools, and educators use it to train new doctors,” she says. This unwittingly perpetuates a system that centers on male physiology and experience.
McGregor describes herself as someone who’s always been interested in women’s history and gender-related issues. When she finished her emergency medicine residency program at Brown University in 2007, she knew she wanted to make women’s lives and health better. But when she told her advisers of her plans, they assumed she wanted to go into obstetrics and gynecology.
Around the same time, studies were beginning to show that women don’t usually exhibit classic heart attack symptoms, like chest heaviness and pain radiating down the left arm. Instead, their symptoms are more diffuse: fatigue, mild discomfort, and even nausea. McGregor began to wonder: If women experience heart disease differently than men, what about stroke? Do they react to drugs differently, too?
McGregor soon realized there was a big, woman-shaped hole in medical knowledge. The National Research Act of 1974 established ethical principles and guidelines to ensure the safety of human subjects involved in medical research in the United States. It classified pregnant women as a “vulnerable” population and excluded them from participating in studies to protect the health and safety of the woman and fetus. Other factors make it more complicated to include women in scientific studies: women’s monthly menstrual cycles throw a kink in the research process, as the fluctuations in hormones create a number of variables that are constantly in flux. To account for these changes, researchers have to test women to determine where they are in their cycle at each point of the research timeline, increasing the cost to conduct the study. “There’s this need to make the research method as simple as possible and remove all the confounders. Women were considered complicated, and so they were removed,” McGregor says.
Mixing research studies with patient stories, Sex Matters shows how the prevailing model of medicine jeopardizes women’s health in very real ways. In doing so, McGregor validates the experiences of women who have come into her emergency department frustrated and defeated because doctors won’t listen to their concerns or have been sent on a wild goose chase from specialist to specialist in search of a diagnosis. “Women who continually come back and seek medical care are often seen as challenging, as complainers, by a lot of people, because they aren’t easy to diagnose. I feel so grateful if I see them. I have this understanding that the emotional piece is real and needs to be valued. They feel heard,” she says.
At the heart of the book, McGregor examines some of the biggest issues affecting women’s health, including cardiovascular disease, prescription drug use, pain disorders and management, and female biochemistry and hormones. She also dives into identity and how race, gender, ethnicity, and religion can affect medical treatment and outcomes.
For example, doctors are more likely to dismiss a woman’s physical symptoms as all in her head. “The mind can cause physical conditions in the body, and physical conditions in the body can cause anxiety. Oftentimes they feedback on each other,” McGregor says. While there is a possibility that a woman’s symptoms could have a psychological cause, doctors often jump to an anxiety diagnosis too quickly when women don’t fit the pattern of disease they’ve been taught to recognize.
Once anxiety is logged in a woman’s medical record, McGregor explains, it sticks with her. The next time she seeks medical care, her medical history may color the doctor’s subconscious perception and evaluation of her symptoms—especially if she comes in with something that’s challenging to diagnose, like abdominal pain or chest discomfort. “They think, ‘Oh, you could just have anxiety,’” McGregor says.
And women start to believe it, too. As they go through rounds and rounds of tests, medication, and follow-up visits, they may start to think it’s psychological and try to rationalize their symptoms.
But there’s a difference between anxiety as a root cause of a medical issue and anxiety as a sign of something else. McGregor says the way women respond to stress can look a lot like anxiety, instead of the classic fight-or-flight symptoms men exhibit. For example, McGregor explains that when a man breaks his arm, he’s supposed to act tough and grimace through the pain. A woman, on the other hand, may cry more freely in public. She may appear anxious not only because she’s in physical pain but also because she’s also thinking of the consequences of breaking her arm—how the injury will affect her work, family, and home life. So, what might look like anxiety on the outside could just be the way a woman’s body processes and reacts to stressful situations, like pain or feeling sick.
Abdominal, pelvic, or menstrual cycle–related pain are all often written off as PMS, a catchall term for a collection of symptoms that may have no underlying cause and which McGregor says is sometimes used when providers can’t figure out what’s wrong. Women are often told to go home to rest, take some ibuprofen, and use a heating pad for the pain. That’s what doctors told Rosita, a patient McGregor describes in her book. Her periods were so heavy and painful that she had missed work. After seeing McGregor in the emergency department and connecting with a specialist, Rosita was diagnosed with endometriosis, a condition in which tissue similar to the lining of the uterus grows outside of the uterus. On average, it can take seven years for a woman to obtain a diagnosis for endometriosis. The negative toll of these undiagnosed years extends beyond a woman’s physical health: it means they are more likely to experience depression, lose productivity and income, and limit their social and daily activities.
Women also metabolize prescription drugs differently than men. Since clinical trials are largely conducted with male subjects and dosing guidelines are the same for men and women, it’s no surprise that women can experience side effects that aren’t accounted for in the research. That’s what happened with the sleep aid zolpidem, often prescribed as the brand-name drug Ambien. In 2013, only after thousands of women reported adverse symptoms like mental confusion, sleepwalking, and even “sleep driving,” the Food and Drug Administration issued sex-specific prescription guidelines for the drug—approximately 20 years after it was first released.
Throughout the book, it can be frustrating to read case after case of how women are undertreated when seeking care. But McGregor makes a clear case that it’s not too late to right the ship.
McGregor says we’re in the midst of a revolution in medicine. She says more doctors and researchers are paying attention to sex differences and are pushing for more research on women. McGregor has helped organize summits on sex and gender health education, bringing together leaders from medicine, dentistry, nursing, allied health, and pharmacy schools to discuss how to integrate sex- and gender-specific factors into curricula. And, importantly, she says the new generation of medical students is keenly aware and attuned to the role sex, gender, race, and socioeconomic factors play in health outcomes and the delivery of health care.
Sex Matters also moves the needle further along. It adds an important dimension to the conversation by educating and empowering patients. It serves as a manual to help women get the right care for their bodies. At the end of each chapter, McGregor includes tips for how women can apply the information to their own lives. She recommends that women take control of their medical records. Take notes during your doctor’s appointments, keep a record of current diagnoses, and snap photos of your current prescriptions. It can be more accurate than what is in your medical record.
She also advises women to ask questions, especially when it comes to medication: Has this medication been tested in women? Should I receive a different dose? Should I take different doses during different phases of my menstrual cycle? What side effects should I expect? Even if your doctor doesn’t know, it will prompt them to seek out the answers.
And be open about why you’re at the doctor’s office. Did you read something online and want to know more? Do you have chronic pain and can’t figure out why? This can give your doctor a better sense of how they can help and meet your needs. McGregor says it can also be helpful to bring along a family member or friend who can help advocate for you.
McGregor believes we’re finally at a point where people realize it’s vital that we include sex and gender differences in medicine. While we might not always find differences between men and women, we have to remove the assumption that we’re all the same. “If we empower women to feel that what they are experiencing is real,” she says, “hopefully the research will catch up.”