By: Catherine Heath
Women’s health issues have traditionally been ignored in patriarchal systems such as our own. The old paradigm viewed half the population as primarily emotional beings whose purpose was to bear offspring and serve the male. Although some progress has been attained in this area, many of the issues facing women continue to be marginalized, negated, and outright ignored by the male-dominated medical community.
A recent shift in attitude (albeit slow) is noted in the literature. Pleas for equality in heath care has apparently spawned what seems to be an increased awareness of female-specific health problems. But has it?? Medical journals are replete with research reports and narrative discussions of breast cancer and issues around menopause, which are, undeniably women’s health concerns. Psychiatric research on affective disorders remains primarily focused on female populations ostensibly because males, for the most part, are not subject to maladies such as depression, anxiety or other neuroses. However, in other areas of concern, the results of studies which utilize predominantly male subjects are generalized to the entire population, as if women and men were physiologically identical. This is not only illogical, but statistically incorrect as well.
Health care policies and attitudes might be considered to be yet another reflection of a culture’s underlying value system, in that those that are most “valuable” to the social system receive the highest quality care. In addition to direct services by physicians and hospitals, this care might take other forms, such as the allocation of research dollars. This paper will attempt to identify some of the problematic areas relative to our male-dominated culture and their effects on women’s health care.
Physiological differences between men and women abound, resulting in differing needs in the areas of health, treatment, and drugs. For instance, postmenopausal women with cholesterol levels above 200 were advised for decades that they were at an increased risk for heart disease, and they must decrease those levels. This recommendation was based on studies conducted on men in which a cholesterol level of 200 or less was determined to be the ideal cutoff point. Recently, however, it has been shown that women with cholesterol levels higher than 295 evidenced the same or lower rate of heart attacks as men with levels of 204. (Fletcher, 1996) Areas of consideration include, but are not necessarily limited to:
Women react differently to medication than men, yet most of the studies have been conducted with male populations. In fact, it was not until 1993 that the FDA’s ban on using women in drug safety tests ended. Over 70% of anti-depressant medication, for example, is prescribed to women despite the fact that the majority of research conducted on these drugs utilized male subjects. (Fletcher, 1996) Apparently too many researchers believe that women and men respond identically to medications.
Women are known to metabolize alcohol differently than men, rendering its effects significantly more unpredictable. (Fletcher, 1996) Due to more body fat and less bodily fluids to dilute the alcohol, women, if given the same amount of alcohol proportional to their body weight, will generally have a higher blood alcohol content (BAC) than their male counterparts. In addition, females in general are more affected by alcohol just prior to the onset of menses and remain intoxicated longer if they are taking any medications containing estrogen as a result of the liver’s functioning to simultaneously metabolize both substances. (University of Illinois, McKinley Health Center, 1996) Despite this knowledge, many researchers continue to focus their studies of alcohol related problems on men. Greenberg and Grunberg (1995), for example reported on the interaction between problematic alcohol behaviors and work alienation. The sample population was only 10% female.
The leading cause of death among women after menopause is coronary heart disease, yet virtually all studies done on this condition have utilized male subjects. A prime example of this is a 1988 study in which researchers concluded that heart attack victims who evidenced a medium to high risk for subsequent attacks could benefit from beta-adrenergic-antagonist therapy. However, the sample used in this study was comprised of 13,385 men - not one woman was involved! (Fletcher, 1996)
Women, on average, normally have lower blood sugar levels than do men. For many years, women were diagnosed as suffering from chronic low blood sugar because males were used in the studies of hypoglycemia, and male sugar levels were used as the norm. (Fletcher, 1996)
Women have never been adequately represented in health research. As noted earlier, the primary problem appears to be the absence of female representation in research samples. According to the 1990 United States Census, 51.3% of the population is female. (U.S. Census Bureau, Missouri State Census Data Center, 1991) Despite this fact, this writer’s review of the Journal of the American Medical Association from July, 1995 through November 13, 1996 yielded some rather unsettling results.
During that period, 83 articles and research studies were presented, and only nine (10.8%) were related to women’s health. Of those, eight were specific to either breast cancer or issues around menopause. (Journal of the American Medical Association, 1995-96) Additionally, a review of the Psychiatric Archives of the Journal of the American Medical Association for that same period revealed there were 121 articles published, and only five (4.1%) mentioned women, while ten (8.2%) pertained to men. (Journal of the American Medical Association, Psychiatric Archives, 1995-96)
Eichler, Reisman and Borins (1990) found evidence of gender bias in all stages of the research process. A careful review of The New England Journal of Medicine, The Canadian Journal of Surgery, the American Journal of Psychiatry, and The American Journal of Trauma for the year 1988 noted gender bias in research design, methods utilized, data collection and interpretation, the titles of articles, and treatment recommendations. Also in 1990, the Government Accounting Office criticized the National Institute of Health for “excluding women from most studies involving diseases, treatments, and drug effects and for devoting only 13% of its research funds to women.” (Fletcher, 1996)
The medical community “continues to mishandle women’s health concerns through negligence, sexism, and sheer inertia. (Nechas and Foley, 1994) The National Women’s Health Network (NWHN) has asserted that this results from an absence of women in decision-making roles that affect women’s health and well-being. Decisions about women and their health are primarily made by men representing hospitals, physicians’ specialty groups and pharmaceutical companies. (Nechas and Foley, 1994)
Patient-physician relationships, although involving mutuality in terms of behavioral expectations, are unbalanced, with the power and status given to the physician. The “culture of medicine” sees this imbalance as necessary, as the physician must be able to exercise leverage over patients to promote a positive change in an individual’s health. Treatments utilized to accomplish the goal of health are oftentimes painful and/or uncomfortable, yet the patient must accept the physician’s recommendation if they are to be effective. This leverage is exercised through three basic techniques; situational dependency, situational authority, and professional prestige. (Cockerham, 1995)
This exercise of control is frequently more evident when the patient is female, who is likely to adopt the dependent role more readily due to societal norms. Many social/contextual issues presented during physician visits are at best, marginalized, frequently negated or ignored, and most often medicalized, with the symptoms warranting treatment by prescription drugs rather than addressing the underlying problem. (Borges and Waitzkin, 1995) For instance, a woman experiencing the difficulties of balancing work, home, and family is most often viewed as being “emotional” and prescribed tranquilizers and/or anti-depressant medications, whereas a man in the same situation is more than likely seen as overworked and the suggestion is made that he “slow down.” (A male physician actually advised this writer to achieve inner peace through prayer and meditation in order to alleviate her hot flashes!)
Confusion around women’s health issues can prove to be financially beneficial to several industries. With physicians serving as gatekeepers to treatment and censors to “accurate” information, women may believe they are opting for treatment which is in their own best interests, however, others may benefit from her decision to use prescription drugs, supplements, and/or screening tests. Included in these commercial interests are pharmaceutical companies (hormone replacements, psychotropic medications, calcium supplements, etc.), the dairy and exercise industries (osteoporosis prevention), hospital and outpatient testing facilities (blood tests, mammograms, etc.), and the individual physician who benefits from medicalization of natural phenomena.
Although there is a substantial body of evidence in the professional literature supporting the benefits of many of these interventions, in several areas, definitive answers with respect to long-term effects are sorely lacking. It is possible that while a misguided (or gender-biased) medical community continues to make recommendations to women, the real beneficiaries are the above mentioned industries. (Coney, 1994)
Providers of health care coverage seem to have achieved a death-grip, as it were, on the health care system. Physicians, hospitals, and outpatient care clinics have become subject to profit-motivated restrictions mandated by insurance companies while attempting to provide appropriate treatment for consumers. For example, according to the National Alliance of Breast Cancer Organizations, 16% of all breast cancers occur in women under the age of forty. Given current statistical projections, 29,488 women under the age of forty will be diagnosed with breast cancer in 1996. The incidence of new cases is also increasing in women between the ages of forty and fifty. Nearly one-fourth of all women diagnosed with breast cancer will die from that disease. Yet the “official” guideline set forth by the American Cancer Society suggests a baseline mammogram at age forty and yearly after the age of fifty, despite the fact that breast cancer is the leading cause of cancer deaths in women aged 35 to 54. (National Alliance of Breast Cancer Organizations, 1996)
This writer questioned the American Cancer Society concerning this issue due to increasing frustration after the death of a close friend, aged 34, from breast cancer. The official policy as stated was that mammograms for screening purposes was not “cost effective” for women under the age of forty, and that except in special cases, insurance companies would not pay for the expensive procedure. Therefore, the American Cancer Society, considered by most people to be the authority on issues related to cancer, has surrendered to the CEO’s (usually male) of the insurance industry. Consequently, approximately 7,088 women will die this year alone due to male-headed insurance concerns establishing policies that effect women’s health (including my best friend).
Areas of Progress
Research on breast cancer and issues around menopause has increased significantly in recent years. Activists from the lay and professional communities have labored many years to secure adequate funding for long-neglected women’s problems.
The NWHN together with the Boston Women’s Health Book Collective testified at congressional hearings concerning the appointment of women to decision-making positions relative to health and well-being. In the mid 1970’s, when the Pharmaceutical Manufacturer’s Association filed suit against the FDA for requiring package inserts in products containing estrogen, consumer groups led by the NWHN filed an amicus brief in support of the FDA. The files from this case clearly indicate that women were fighting against male providers (and their monied interests) once again. (Nechas and Foley, 1994)
Continued lobbying has served to increase awareness around these issues and helped to increase research funding as well.
As previously noted, the Government Accounting Office released a scathing report in 1990 which criticized the National Institute of Health for disproportionate allocations of research funding as well as exclusion of women from most studies. Women subjects are currently permitted to participate in the FDA’s drug safety studies, as mentioned, primarily as a result of these efforts. (Fletcher, 1996) Random review of several journal articles also indicates the number of women utilized in recent studies is increasing, and although not a representation of the general population as yet, this might possibly be indicative of a positive trend for the future.
According to Thomas Weiss (1995), the Department of Veterans’ Affairs has made considerable improvements since the early 1980’s, and the Veteran’s Health Care Act of 1992 has allowed for further expansion of services to female veterans. Women comprise 12% of the United States’ military forces, and represent the fastest growing segment of the veteran population. During the ten year period from 1980 to 1990, female veteran’s utilization of VA hospitals increased dramatically when compared to men.
The age-adjusted hospital discharge rate (#discharges/veteran population) increased 22% for women and only 0.5% for men. The age adjusted user rate (#unique users/veteran population) for this same period shows a 9.5% decrease for males while increasing nearly 12% for female veterans. Weiss believes that recent initiatives to remove barriers and increase services will also provide a foundation for further expansion of health care for women, promote change in provider attitudes, serve to increase knowledge and expertise in women’s health issues, and foster an environment more accepting of women in the future.
Throughout Western history, male dominance has been perpetuated /supported by government agencies, legal systems, and religious doctrines which have their roots in traditional English law. Inequities in health care coexist with the continuation of male dominance, and as women persevere for equal status, they bring with them many issues centered around their health concerns. Some strides have been made in changing the attitudes of many professionals, however, unless equality is established at the cultural level, continued struggles seem inevitable.
The slow, yet deliberate, shift in professional attitudes might be enhanced in several ways. Medical students could be exposed to a more accurate representation of the population while in school, rendering them better prepared to deal with their patients realistically. Research, unless focused on a gender-specific concerns such as menopause or prostrate cancer, would be better able to generalize results to the entire population from data gathered by means of a truly representative sample. Support of activist groups lobbying for equity in research funding could foster more accurate research methods and political alliance with these same groups might serve to enhance the establishment of women in decision-making roles as well. Most importantly, women themselves need to become informed health consumers, assertively dealing with those physicians and agencies that choose to negate, marginalize, or ignore their complaints and/or concerns.
Inasmuch as health care policies and attitudes reflect the values of a culture, no enduring change will be seen until women are as valued and respected as men are. As with other social issues, change is slow. Biases and prejudices gathered over a lifetime are difficult, if not impossible, to alter. Until such time as both women and men are treated with the dignity and respect deserved, these attitudes will continue to divide us along sexual lines and negatively impact health care - especially for women. To this end, the struggle for equality must continue.
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