Historically it was assumed that there was no fundamental difference between the sexes beyond the glaringly obvious, as Caroline Criado Perez writes in her thoroughly well researched book Invisible Women, which examines the plethora of gender data gaps in multiple areas of life, not least health care.
It's not very uplifting to note that the ancient Greeks regarded the female body as a mutilated male body. Of course, modern medicine does not hold this view and yet in so many areas of life, not just medicine, the male body is considered the default. As this post is centred on the health implications of this apparent bias, I'll leave aside issues such as the design of cars with regard to driving positions, although since women drivers, who typically have fewer accidents than men, are at proportionally greater risk of death compared to men, is this perhaps relevant here anyway?
Women have been frequently excluded from medical research over the years and, despite more recent interventions from certain governments to respond to the imbalance, the trend persists precisely where much of the research is carried out. Research conducted by drug companies may only be subject to guidelines rather than requirements to adhere to legislation, meaning that unwelcome guidelines are routinely given little more than lip service or are completely ignored. Why? Because it's 'messy', time consuming and subsequently costly to recruit women whose hormones fluctuate creating different physical outcomes over the course of 4 weeks, not to mention the possibility that an entire cohort of that gender is of childbearing age and may thus become pregnant, making testing even more chaotic, as well as being potentially highly unethical.
So if you were wondering whether or not this matters, isn't it precisely these factors that emphasise that it does? Women make up half of the human population; how can their health not be fully addressed? The fact that there are more biological considerations with respect to women's physiology mustn't be a reason to simply exclude them and hope that male-tested drugs will work in the same way in women, yet frequently this is what happens. Women who are involved in studies are most likely to be tested in the early follicular phase of their cycle because this is when there's the least hormonal activity, thus making it 'easier' for the researchers. The problem with this, of course, is that women pass through other phases every month and these can, and sometimes do, impact on their responses to medications. Dosages at different times may prove to be too low or too high as has been the case with some antidepressants. Additionally, according to the research carried out by Criado Perez for her book, "women are more likely to experience drug-induced heart rhythm abnormalities and the risk is higher during the first half of a woman's cycle. This can, of course, be fatal." Testing of certain medications for women then, effectively makes them walking lab rats, with the test taking place in real time (as opposed to the controlled conditions of a trial), and without their knowledge - do you know a drug's research history before you take it? Some then pay with their lives.
Diagnoses for women are sometimes also similarly flawed. The issue of women and heart disease is one of the better known instances of poor diagnosis: “Despite the fact that 35% of deaths in women each year are due to cardiovascular disease, women continue to be underdiagnosed and undertreated,” stated a 2021 report in The Lancet medical journal. This is due in no small part to the nature of the symptoms for women being different from those experienced by men. An article in Spain's El Pais newspaper from September this year offers the following: "The experts explain that, on the one hand, women get checked out later and are less aware of cardiovascular disease, but doctors also tend to underestimate the symptoms or, when they have a diagnosis, to be more conservative in their treatment." And again, research is an issue with fewer women taking part in trials: “Women under 55, for example, are not recruited because they menstruate and this can influence the result. With ischemic heart disease, many antithrombotics and anticoagulants are used, which will increase menstrual bleeding and they will have more anaemia and more side effects.” With such a time sensitive condition, diagnosis and treatment must happen quickly to avoid inevitable fatalities. This is clearly not yet happening as it needs to.
Less urgent but still rather dismal is the effective lottery of a fibromyalgia diagnosis. A 2007 paper indicated that women with fibromyalgia symptoms fulfilled the diagnostic criteria for the condition during the luteal phase of their cycle, but not during the follicular phase. There is a link to breathing here, hence my particular interest as a breathing instructor. Female breathing is different from male breathing which has been known since 1915! It was found that women hyperventilate during the luteal phase of their cycle. Later, in 1929, research confirmed that these cyclical variations in breathing are no longer present in post-menopausal women which clearly links breathing with fluctuations in sex hormones. Did you know this? You probably didn't. Once again, it's an under-researched area joining forces with another: correcting and adapting breathing patterns can assist with symptoms of PMS but if you've experienced PMS and sought medical help, the chances are you've been prescribed a drug, and how you breathe will not have been so much as mentioned. Breathing can be as damaging or healing as food, and yet neither feature significantly in any medical response to the maladies that can and do respond well to these simple, cost-effective and mostly completely harmless interventions.
Of course, a focus exclusively on women only serves to highlight women. But what about other groups? Are vegans tested alongside omnivores? Since the microbiota of each group will display significant differences, what might this mean in terms of pharmaceutical interventions? And of course, there's a growing group of people also effectively excluded from trials, namely those already taking other drugs, sometimes a cocktail of drugs each with potential adverse reactions. They too are walking lab rats delivering difficult-to-use results by virtue of their bio-individual responses to any and all of the drugs they're taking and the impossibility of testing every combination of drugs whether prescribed or bought over the counter.
My hope is that our understanding of bio-individuality will grow alongside our understanding and acceptance of fundamental gender differences and that the subsequent responses will only include, rather than prioritise pharmaceuticals. For many conditions and ailments the best response may be to support our physiology and mental health by how and what we eat and by relearning how to breathe optimally (since many of us don't), not to mention movement, social interaction and effective rest and sleep.
~ Annette Henry
