Full disclosure: I’m partial to female physicians, at least when it comes to women’s health. After all, would you go to an ear doctor who doesn’t have ears?
Some of my bias stems from the fact that, historically, male doctors have doubted everything from PMS to the pain of childbirth, going so far as to explain menstruation as the womb weeping for the absence of a baby (with roughly 450 menstrual cycles in a woman’s life, that’s one sad uterus). And some of it is due to my own experience. In trying to find the cause of chronic abdominal pain, I visited six specialists—five were women, one was a man. The male physician was the only one to suggest my pain was psychological. Eventually, the physical cause of the pain was discovered and treated by one of the female doctors.
So, is there any evidence to support my skepticism? Yes and no. But more importantly, the question underscores gender issues that have plagued medicine throughout history, some due to sexism and some just from confusion. Still, there’s hope that with the equalizing number of women and men in the field, a day of gender-neutral health care is dawning.
Here’s a question for you: As a patient, do you know the difference between your sex and your gender—or why it matters?
Your sex is determined in utero the moment you were assigned to chromosomal team XX or XY. Every gene is affected by which jersey you wear, ultimately leading to major differences in your health down the line (think life expectancy, heart disease, reproductive cancers). Your sex will determine your health.
Your gender is how you present yourself as male or female, and that distinction is weighed down by a bunch of environmental factors piled onto the biological ones (think pain management, treatment of depression, cancer awareness). It’s your gender that will determine your health care.
Throughout history, women’s and men’s health have been treated differently. Although both women and men shared various epidemic diseases, gruesome infections, and untimely deaths, the focal point of women’s health care has always been their reproductive health. It’s what sets them apart as patients and what has created the chasm in male understanding of female health.
And for good reason. Female reproductive health is the basis for all of human life. It’s a healthy process that historically didn’t need much medical intervention. For that reason, in our early history, women’s health was a field practiced almost entirely by women midwives. Sometimes that was due to strict religious practices. But for the most part, it was due to the knowledge and experience these women had in delivering babies and teaching basic mothering skills—the Middle Age version of What to Expect When You're Expecting.
Health care in general—and particularly for women—wouldn’t see dramatic changes until the end of the nineteenth century when medicine became an actual scientific field requiring degrees and licenses. As only the educated could pursue those degrees, it also became a field dominated by men. Women’s health care transitioned from the practiced hands of midwives to the newly educated male physicians who were eager to apply scientific understanding to a largely undeveloped medical field.
Grappling for an understanding of the fairer sex, Victorian physicians coined hysteria as the catchall for women’s ailments. See if these symptoms sound familiar: irritability, bloating, headache, insomnia, lack of interest in sex. Essentially, hysteria made PMS certifiable. Physicians missed the mark on treatments, but they were at least correct in suspecting hormones as the underlying cause of many female health complaints.
The mainstay of women’s health care—childbirth—remained controversial. Physicians delivering babies in the 1910s and 20s had higher maternal mortality rates due to infections acquired in hospitals (washing your hands was a novel idea). Many women opted for home births and midwives well into the 1930s.
Male doctors did their best to understand and facilitate childbirth. One of the more disturbing examples of this came from a 1948 study in which women’s hands were burned during labor to measure their threshold for pain. As horrific as it sounds, the women volunteered for the study and most were nurses or married to doctors. They felt that a scale quantifying pain would be useful to medicine in general. All were given the choice to stop the experiment and receive anesthesia at any time. Nonetheless, the details are cringe-worthy. They asked women to assign a number to pain in early labor—from zero to 10.5. Most women scored between 2 and 4. In between contractions, doctors applied heat pulses to the women’s hands. Scores were similar. As labor progressed, reaching the maximum 10.5 on the scale, the women did not react to increases in heat—so much so that some received second-degree burns. The objective of the study was to apply a quantity to pain. It was a failure on that front, and pain measurements (known as dols) never caught on in mainstream medicine. But the study did succeed in proving that, yes, labor hurts. A lot.
A far more humorous experiment was one conducted last year by a pair of male journalists from the Netherlands who set out to prove that their wives exaggerated the pain of childbirth. Electrodes were attached to their abdomens to feel exactly like labor pains. If you haven’t seen it, it’s worth a watch on YouTube if only to see two hospital-gowned men curled into the fetal position, wailing in pain, as their wives nod to each other in the background. After two hours, the men begged for the experiment to stop. They were exhausted and self-congratulatory until the nurses informed them they’d only made it to early labor—the average woman would have had another ten hours to go with progressively worsening pain. Apparently, when it comes to childbirth, it’s not in your best interest to “man up.”
Mama’s Little Helper
Though the first half of the twentieth century was an exploration in the science of women’s bodies, the focus on women’s mental health swiftly evolved from hysteria and psychotherapy toward pharmacology. It was a dark evolution—perhaps, in part, because it was a reflection of the rapidly changing role of women. It began the decades-long trend that still exists today to medicate women.
Advertising has always been a litmus test for those attitudes. Everything from cocaine-laced cola to Ritalin, sold as “mama’s little helper,” promised to give a woman the energy needed to be a good mother. From there, Valium and drugs akin to horse tranquilizers were marketed to women so they could relax and stop being so anxious in their role as wife and mother. Today, it’s the SSRIs and the cartoon gray cloud following around a depressed mother overwhelmed by “trying to have it all.” Are you seeing a pattern here? In lock step, physicians began prescribing medications to cure that hiccup in female psychology.
Today, you can find numerous studies questioning why women are prescribed so many more medications than men. In the case of antidepressants, it’s 2 to 1. In truth, there are probably many factors at play—certainly more than just a shift in gender roles. Men do not see doctors as regularly as women. They are not as likely to complain about emotions to their physicians. And, most importantly, depression is expressed differently in men than women. In women, sadness, dullness, and loss of interest in everything from sex to extracurricular activities are hallmarks of depression. In men, it manifests itself differently—sleep disturbances, irritability, aggression, outbursts. A recent study in the Journal of the American Medical Association found that when you account for those symptoms, men and women suffer from depression in comparable numbers.
Here’s where my inner feminist jumps in. Those traits evident in depressed men seem culturally acceptable as part of their general, testosterone-bathed being. Men are expected to lose it sometimes with all the stress they endure. With all the stress they’re under, society reasons, it’s bound to happen.
The same cannot be said for women. Irritability, frustration, sadness—the sister traits of depression—are unbecoming in a woman. You yell at a colleague and you’re a raging head case fueled by hormones. You cry from exhaustion as you get up the third time in a night to breast-feed and you have postpartum depression. You lose it when your toddler goes postal in the aisle of Target and you’re a traitor to motherhood. Is it any wonder then that large numbers of women have spent decades on prescription meds?
To be clear, I don’t take issue with the use of antidepressants. If you take them, more power to you. I worry instead about the reason they are prescribed. Perhaps women are medicated as often for what society believes we shouldn’t feel as we are for what we actually feel.
Is PMS real? Believe it or not, that has recently been the subject of several medical studies. In part, because medicine today is attempting to truly understand the difference between sex and gender in overall health. How much of women’s health is dictated by that XX chromosome and how much is imprinted on her as part of her gender?
Any woman who has experienced pregnancy can tell you it’s a total system reboot. Whether you’re tripping over the curb thanks to hormones relaxing your joints or dry-heaving in the milk aisle from that super-sensitive sense of smell, everything from the texture of your hair to the size of your feet will change thanks to pregnancy. It shouldn’t come as a huge surprise then that those same hormones will also do a number on you during your regular monthly cycle. That’s why I have a hard time believing the latest PMS studies that suggest environment has more to do with it than biology.
On the one hand, they’re setting out to prove that you can’t blame a woman’s every grumpy mood or incident of road rage on hormones—kudos to that. People under stress will react differently, regardless of hormones or gender. But some researchers go so far as to suggest your own culture will define how you experience PMS. If a woman is expected to be a banshee, she will be because outside influences are at play.
I see it differently. Take a human—woman or man—and within a few hours make them more sensitive to sight, smell, and sound, unable to sleep, chemically incapable of experiencing a sense of calm, bloated a full pant size larger with a well-placed pimple on the chin, and a dip in serotonin levels severe enough to trigger migraines and a sense of hopelessness. Tell me that person is not going to have a bad day. Are men just as capable as women of having emotional fluctuations? Sure. Theirs just aren’t almost entirely due to hormones and conveniently tracked on a 28-day calendar.
More important than how we personally feel about PMS is its role in women’s health. One current study is looking at the connection between PMS and hypertension later in life. That little thunderstorm of hormones may share many of the same underlying factors that contribute to heart disease. Also, migraines caused by a drop in estrogen during PMS are very common, and migraines are a risk factor for ischemic strokes. Researchers are starting to look much harder at the connection between hormones and health later in life.
So, what roles do sex and gender play in our health care system today? For many years, it was believed that medical studies focused too much on men and too little on women, a notion that may have been more politically motivated than scientifically based. As a result, in 1990, the National Institutes of Health created the Office of Research on Women’s Health. One of its missions is to do away with some of the confusion surrounding sex and gender and to raise awareness about the ways in which those XX or XY chromosomes will affect illnesses and treatments.
Just a short list of current research projects: post-traumatic stress disorder in victims of domestic abuse, aspirin as prevention for heart disease in women, programs reducing sexual violence on college campuses, a bacteria that may slow HIV in women, different ways health care can reach low-income and minority women who do not regularly see a doctor (did you know cervical cancer can be detected by a tampon?), and why women drop out of medical academia and research at much higher rates than men.
How do we level the gender playing field in medicine? We start by meeting in the middle. Most prejudices in medicine came about in the last hundred years or so when only men brought their ideas of gender to the profession. Right now, medical schools have an equal number of men and women. The current trend is toward teaching young doctors how to communicate better, listen more, and involve patients in their decision-making. Women tend to excel in those areas. In fact, women doctors spend 10 percent more time with their patients—even at the expense of seeing fewer patients and earning less money. If we are to have health care that works succinctly, both men and women physicians need to contribute their experience and knowledge to the overall understanding of human health.
And what of my own gender biases in medicine? I’m very happy with my woman doctor. Is it because she’s not a man? Not really. I like her because she’s like me—she is a working mother. She knows from personal experience tricks like cutting the morning-sickness-pill in half to stop nausea without falling asleep at work. Because she’s friendly enough to know the names of my kids, but rigorous enough to insist on baseline mammograms at the age of 35. And because I suspect her greatest personal worry is the same as mine—the fear that poor health might cut short motherhood.
Recent studies suggest that doctor-patient relationships are based on personality far more than gender. Plenty of women will tell you they’ve had better experiences with male doctors than female ones. And vice versa. In a perfect world, that’s how it should be—gender-blindness for both the physician and the patient, so that we can see clearly the ways our sex ultimately affects our health. If we can get to that point, I just might be able to forgive those early male physicians for believing all of my illnesses were caused by a “wandering womb” ping-ponging around inside me.
Photo by Julie Cate Photography