Maya Dusenbery Follow

Executive director of editorial at Feministing.com

Mar 23, 2015 11 min read

Is Medicines Gender Bias Killing

YoungWomen?
By Maya Dusenbery

Heart disease is the number one killer of both men and women in the
United States, yet its long been considered a mans disease in the
popular imagination. This perception likely stems, in part, from the
fact that coronary heart disease, the most common cause of heart
attacks, is more prevalent among men and tends to strike them at a
younger age. When younger women do have heart attacks, though,
studies have found that they are about twice as likely to die as their
male counterparts and more than 15,000 women under the age of
55 do every year.

But focusing on what individual women do or dont

do when theyre having a heart attack is a way of
subtly shifting the blame for the deep and systemic
failures of our health care system onto itsvictims.

For decades, studies have attempted to tease out the various factors
that may contribute to that signicant gender gap. Recently,
researchers at the Yale School of Public Health published a qualitative
study exploring the experiences of women under the age of 55 who
had been hospitalized for a heart attack. The main take-away
according to most headlines summing up the results seems to be
that younger women may ignore or dismiss their symptoms and
hesitate or delay in seeking care, in part out of anxiety about
raising a false alarm.

But focusing on what individual women do or dont do when

theyre having a heart attack is a way of subtly shifting the blame for
the deep and systemic failures of our health care system onto its
victims. In reality, the themes that emerged from the interviews with
30 women in the Yale study, as well as previous research on women
and heart attacks, paint a more complicated and even more
disturbing picture of how gender bias plays out on multiple levels,
both within and outside the medical system, to aect womens ability
to get life-saving care in a crisis.

. . .

Over the past couple of decades, public education campaigns have

gradually increased awareness that heart disease is a major health
threat among women. But many of the interviewees in the Yale study,
even those who had a family history of the disease, underestimated
how much they were personally at risk, often guring that they were
too young to be having a heart attack. They also had a fairly
stereotypical idea, gleaned mostly from popular media, of what it
would feel like: the sudden onset of chest pain and shooting left arm
pain that marks the Hollywood heart attack. So when they began to
experience symptoms like jaw pain, upper back pain, a feeling of
indigestion, nausea, and fatigue the atypical signs that women are
more likely than men to get they tended to attribute them to other
health problems.

Although more women than men have died each year

from cardiovascular-related causes since 1984, fewer
than one in ve doctors primary care physicians,
OB/GYNs, and even cardiologists surveyed in a 2005
study knewthat.

To an alarming degree, their misconceptions simply mirror the

ignorance about womens heart disease in the medical community.
Although more women than men have died each year from
cardiovascular-related causes since 1984, fewer than one in ve
doctors primary care physicians, OB/GYNs, and even cardiologists
surveyed in a 2005 study knew that. And they tended to
underestimate female patients personal risk for the disease,
recommending fewer preventative measures to them compared to the
men. Health care providers also seem to be on a rather steep learning
curve when it comes to understanding how womens experiences may
diverge from the textbook heart attack. In 1996, a national survey
revealed that two thirds of doctors were completely unaware of any
gender variations in symptoms. Last year, a poll of physicians
commissioned by the Womens Heart Alliance found that only about
half agreed that there were dierences between mens and womens
hearts.

Of course, the fact that womens heart attacks are less likely to adhere
to the textbook model is not exactly an accident, since the textbook
was, quite literally, written based on what mens heart attacks look
like. Though theres been slight improvement since the National
Institutes of Health Revitalization Act mandated proportional
representation of women and minorities in clinical trials in 1993,
recommendations for preventing, diagnosing, and treating heart
disease continue to be largely extrapolated from research conducted
on white, middle-age men. A review of the American Heart
Associations 2007 prevention guidelines for women, for example,
found that they drew on studies in which women made up only 30
percent of the subject population. Only one third of the studies even
broke down the results by gender.

What modest progress has been made in closing this gender gap in
the clinical studies has led to some real shifts in practice and
probably contributed to the decline in cardiovascular-related mortality
rates, especially pronounced among women, since 2000. Last year, the
American Heart Association credited recent gender-specic research
with improving the diagnostic processes for non-obstructive coronary
heart disease in women. For decades, doctors used the male model of
coronary heart disease testing to identify the disease in women,
automatically focusing on the detection of obstructive coronary artery
disease, AHA cardiologist Jennifer H. Mieres explained at the time.
As a result, symptomatic women who did not have classic obstructive
coronary disease were not diagnosed with ischemic heart disease, and
did not receive appropriate treatment, thereby increasing their risk for
heart attack.
In all likelihood its mostly thanks to these improvements in catching
and managing coronary heart disease before it causes a heart attack
that the mortality gap between younger women and men has begun
to narrow in recent years. Its less clear if health care providers have
become any better at recognizing and quickly responding to heart
attacks in women when it does get to that point. Like their patients,
doctors remain slower to act when symptoms dont conform to the
classic model. A 2012 study that tracked more than 1.1 million heart
attack patients from 1994 to 2006 concluded that this helped explain
why 15 percent of the women died in the hospital, compared to 10
percent of the men. Patients who never experienced chest pain were
nearly twice as likely to die, due in part to delays in getting life-saving
interventions. And women, particularly younger women, were
overrepresented in this group: 42 percent of the women didnt have
chest pain, compared to only 31 percent of the men.

. . .

But attributing the disparity entirely to a dierence in symptoms may

actually understate the gender bias at play. Among younger patients
in the 2012 study above, gender played a role independent of
symptoms, chest pain or not. In the Yale study, too, while the
interviewees had a range of symptoms, including atypical ones, the
vast majority of them 93 percent did indeed have chest pain. And
they told stories of unresponsive health care providers and delays in
getting timely work-ups when experiencing both atypical and typical
symptoms. One woman, for example, called her doctor to report chest
pain and was told to schedule a regular appointment ve days later.

The presence of stress, the researchers explained,

sparked a meaning shift in which womens physical
symptoms were reinterpreted as psychological, while
mens symptoms were perceived as organic whether
or not stressors were present.

A series of studies led by psychologist Gabrielle R. Chiaramonte in

2008 provides some clues as to why that may be. In the rst study,
230 family doctors and internists were asked to evaluate two
hypothetical patients: a 47-year-old man and a 56-year-old woman
with identical risk factors and the textbook symptoms including
chest pain, shortness of breath, and irregular heart beat of a heart
attack. Half of the vignettes included a note that the patient had
recently experienced a stressful life event and appeared to be anxious.
In the vignettes without that single line, there was no dierence
between the doctors recommendations to the woman and man.
Despite the popular conception of the quintessential heart attack
patient as male, they seemed perfectly capable of making the right
call in the female patient too.

But when stress was added as a symptom, an enormous gender gap

suddenly appeared. Only 15 percent of the doctors diagnosed heart
disease in the woman, compared to 56 percent for the man, and only
30 percent referred the woman to a cardiologist, compared to 62
percent for the man. Finally, only 13 percent suggested cardiac
medication for the woman, compared to 47 percent for the man. The
presence of stress, the researchers explained, sparked a meaning
shift in which womens physical symptoms were reinterpreted as
psychological, while mens symptoms were perceived as organic
whether or not stressors were present.

That was when the patients did experience the classic heart attack
symptoms. In the next twist on the study, the researchers asked 142
family physicians to assess a male and female patient presenting with
atypical symptoms, including nausea and back pain. This muddied the
picture further: The woman was slightly less likely than the man to
receive a heart disease diagnosis, but neither was likely to get one at
all. And when stress was added to the mix, both men and women
became even more likely to be diagnosed with a gastrointestinal
problem instead. Given that women more commonly have both
atypical symptoms and signs of anxiety, the end result is, yet again,
that women are left under-diagnosed.

In Chiaramontes studies, the hypothetical patients had the exact

same risk of a heart attack according to their age group. Given that
younger women are, on average, at lower risk for heart attacks than
younger men, the tendency to dismiss their symptoms as anxiety is
likely even greater.

Thats what a 2014 study looking at over 1,000 patients, aged 18 to 55,
who had heart attacks in Canada, the United States, and Switzerland,
suggests. The study found that men received faster access to cardiac
testing and care than women; the average time it took for men to get
an electrocardiogram, for example, was 15 minutes, compared to 21
minutes for women. While some factors including an absence of
chest pain seemed to cause delays in both genders, anxiety was
associated with the failure to meet the 10-minute benchmark for ECG
only in treating female patients. The researchers also gave the
patients a personality test gauging how closely they adhered to
traditional gender roles and found that both men and women with
more stereotypically feminine traits faced more delays than patients
with masculine traits.

. . .

Feminist critiques of modern medicine have long noted that,

particularly when the cause of an ailment is unknown, doctors default
to a psychological explanation in women more than in men. There are
certainly some factors that may heighten this tendency when it comes
to heart attacks. After all, only 20 percent of people who come to the
ER with chest pain are actually having a heart attack. There is also
clear symptom overlap between a heart attack and an anxiety attack,
and younger women are at relatively lower risk for the former and
higher risk for the latter. This reality, the Yale researchers suggest,
might contribute to initial triage strategies to attribute symptoms to
non-cardiac conditions in young women. One cardiologist put it more
bluntly: In training, we were taught to be on the lookout for
hysterical females who come to the emergency room.

In training, we were taught to be on the lookout for

hysterical females who come to the emergency room.

But to a large degree, that sentiment reects the kind of treatment

many women receive from the health care system as a whole. The fact
that psychological problems, like anxiety disorders and depression,
can have a wide range of non-specic symptoms means they can
serve as remarkably plastic diagnoses. To take just a few examples
from the experiences of young women I know: For a month, multiple
health care providers insisted that a friends stabbing chest pain was
likely just anxiety before they realized it was pericarditis, an
inammation of the lining around the heart that causes symptoms
similar to a heart attack. Dizziness, wooziness, ringing in your ears,
and oaters in your eyes? An infectious disease specialist suggested
that another friend see a therapist for depression, when she was
actually suering from West Nile virus. Others have encountered
physicians eager to play armchair psychologists and explain away the
fatigue and widespread pain of bromyalgia, and the abdominal pain
and incontinence of a ureaplasma infection.

This pervasive bias may simply be easier to see in the especially high-
stakes context of a heart attack, in which the true cause usually
becomes crystal clear too often tragically in a matter of hours or
days. When it comes to less acute problems, the eect of such medical
gaslighting is harder to quantify, as many women either accept
misdiagnoses or persist until they nd a health care provider who
believes their symptoms arent just in their head. But it can be
observed indirectly: In the ever-increasing numbers of women
prescribed anti-anxiety meds and anti-depressants. In the fact that
women make up the majority of the 100 million Americans suering
from (often under-treated) chronic pain. In the fact that it takes
nearly ve years and ve doctors, on average, for patients with
autoimmune diseases, more than 75 percent of whom are women, to
receive a proper diagnosis, and that half report being labeled chronic
complainers in the early stages of their illness. Then there are the
diseases, like chronic fatigue syndrome and bromyalgia, that exist so
squarely at the overlap of the Venn diagrams of aects mostly
women and unknown etiology that theyve only recently begun to
be recognized as real diseases at all.

And it can be seen, too, in the women who simply disengage from the
system altogether. In the Yale study, interviewees reported limited
and sporadic connections with primary care for routine check-ups
and preventive heart care. In part, this was due to structural barriers
 such as lack of insurance and little time between work and family
responsibilities that other research has found tend to
disproportionately aect women. But some interviewees also
explained that they were concerned about being perceived as
complaining about minor concerns and had had negative experiences
with health care providers in the past: poor physician-patient
relationships, feeling rebued or treated with disrespect, and being
denied care. Its hardly surprising that many also reported being
hesitant to seek help when they suspected they might be having a
heart attack for fear of being perceived as hypochondriacal.

This fear didnt fall out of the sky. And while it cant be blamed solely
on the health care system, it also cant be separated from the medical
establishments systemic failures to study, understand, and take
seriously womens health concerns.

Fixing these bigger problems lack of access to preventive care, the

gender bias in medical research and education, the psychologization
of womens ailments is hard. Its much easier to conclude that we
just need to empower women to recognize their symptoms and seek
help without fear of judgment. But thats just a way of saying that
individual women need to compensate for the health care systems
biases: that they should know their risk of heart disease better than
their doctors do, should be able to identify the symptoms of a heart
attack more readily than their doctors can, and should demand care
and be prepared to ght for it in spite of their doctors tendency to
dismiss them.

Call me crazy hysterical, even but I dont think you should have to
feel that empowered just to receive proper medical treatment.

The Gender Gap explores the persisting gender inequalities of the modern
age and societys unwillingness to grapple with them.

Lead photo: Seems like depression, no? (Photo: caliorg/Flickr)