Gender equality has been a long-held dream, fought for by women and our allies for decades, yet according to the 2022 Global Gender Gap Report, we still have 132 years to wait for gender parity. That's if we continue at our current rate of progression. Unfortunately, the report also found that the risk of us backsliding rather than making progress is very real, so even that intangible 132-year finish line isn’t guaranteed.
In the battle for gender equality, healthcare is key. If women’s health needs aren’t being met or our access to the right care isn’t available, it impacts every other aspect of our lives and how we are able to contribute to the workplace, at home or to society at large. Historically, healthcare, like every other societal construct has deprioritized the needs of women, viewing us as subordinate and dismissing us and our ‘fluctuating hormones’ as too complex to study. For decades, studies took the male body as ‘the norm’ and this became built into the very foundations of medicine.
Although things are slowly changing, this historic bias and how it has played out in the development of clinical research and medicine has made women sicker and resulted in poorer outcomes across a variety of conditions including chronic pain, bleeding disorders, autoimmune conditions, mental health and cardiovascular issues. It has also led to a lack of advancement in understanding, diagnosing and treating health conditions that only impact women and those assigned female at birth.
So where did it all begin?
Gender bias in medicine can be traced back as far as the Greek philosopher Aristotle who described women as ‘mutilated males’ with their "genitalia turned inside out". Women were perceived as the subjects of male rule with one job and one job only... to procreate.
Aristotle added that women were more ready to weep and to be "subject to depression of spirits and despair than the male". This view is often seen as the catalyst for one of the hardest to shake, ingrained biases within healthcare, that women’s pain has an emotional or psychological cause rather than a physical one.
Despite the advancements that have been made since medicine became rooted in science, rather than constructed in historic opinion, and thanks to the tireless work of feminists across the generations, recent research highlights how much power this myth still wields. One study from 2018 found that doctors often view men with pain as ‘brave’ and women as ‘emotional’. It went on to reveal that women are less likely to receive effective pain relief and more likely to receive a mental health referral than men.
This view that women’s bodies are ‘other’, that men are the ‘norm’ continues to impact nearly every corner of healthcare, from the diseases that are allocated the biggest research budgets to how patients are perceived by clinicians, right through to securing a diagnosis and effective treatment.
The impact of gender bias in healthcare
Women have been excluded from, or been lacking in, clinical trials and research both historically and up to this very day. This has impacted understanding of how diseases impact women and how drugs for different conditions affect us. Most drugs are prescribed to men and women in the same doses, but a recent study looking at how different drugs impacted these two genders highlighted that in more than 90% of cases women experienced stronger side effects than men.
Although hard to believe, it was only in relatively recent history (1993) that a landmark ruling in the US, stating that women should be included in clinical trials, came into effect and began impacting trials on a global level. It means that studies that pre-date this, have huge blind spots when it comes to understanding female health and it’s an ongoing process to get trial numbers to a point where women have equal representation.
As well as the lack of knowledge surrounding women’s health, historical studies and beliefs have a knock-on effect as to how women are dealt with when they present with concerns at a healthcare setting. Research from the British Heart Foundation showed inequalities at every step for women in their medical journey with heart concerns, primarily because there is a long-held belief that myocardial infarction (a heart attack) is a male issue. The data also revealed that women are 50% more likely to receive the wrong initial diagnosis when having a heart attack.
And that’s just one condition.
Data on conditions that only impact women show stark differences in funding levels to those diseases that also impact men. This gap is clear in figures from the National Institute of Health that reveal that diabetes receives 1,500% more funding per woman than endometriosis. Which is hugely significant when you consider that it affects nearly the same number of women as endometriosis, which remains a hugely understudied and underfunded condition.
Equity versus equality
Equity, a term that often gets used interchangeably with equality, is one of this year’s International Women’s Day themes... #EmbraceEquity. It’s a concept that many believe should underpin all conversations regarding gender equality, because it recognises not every woman starts from the same place and that we can’t make everybody equal by handing them the same tools and resources.
The term ‘women’ is a broad one. Lack of representation and bias within healthcare are further intensified for women of colour, those living with disabilities and those from different socio-economic backgrounds as well as the trans and non-binary community. Women living with long term health conditions such as PCOS or endometriosis are also not starting on a level playing field. Taking all of this into account, we can’t expect to find a ‘one size fits all’ solution to gender health inequality.
Since we started Joii in 2019, we have read hundreds of research papers, spoken to countless women and medical professionals and heard dozens of heart-breaking stories. As we evolved through these experiences, the need to address equity as a key factor on the road the gender health equality became ever clearer.
Better diversity of representation in clinical trials and reporting of that representation
Traditionally medical research has been done on healthy young and middle-aged men, with women underrepresented at best, and omitted at worst. Whilst there has been some improvement in the number of women taking part in trials in recent years, there is still a lack of diversity in the women that are included.
The issues here are many. Very few trials report the intersection of race and gender, so the number of women will be noted and the number of participants of colour will be noted but no one is reporting on how many women of colour take part. Not only does it make it hard to fully understand the deficit of representation, but when race and gender are not reported that means there is a serious lack of data for that population regarding how the drugs or vaccines being trialled work for them. Or how they are impacted by different diseases and conditions.
In the area of menstrual health, this plays out in many ways, but not least in the diagnosis of endometriosis. Research has shown for instance, that Black women are less likely to be diagnosed with endometriosis overall than their white counterparts, but it doesn’t mean they are less likely to have it. Misdiagnosis is a key factor, with endometriosis being mistaken for other conditions such as fibroids, because Black women are more likely to be impacted by them. Implicit bias in the medical community relating to how Black people feel pain also plays a part.
The only way to truly understand how endometriosis impacts Black women, is to ensure they are featured in clinical trials in the same numbers as white women and women from other ethnic backgrounds.
Menstrual equity through education and understanding
Those living with menstrual health conditions lose up to 84 days a year to their symptoms. This means missing out on school, work, exercise and social events. Despite living with debilitating pain each month, numerous individuals speak of the years they spent being dismissed or told their symptoms are “normal” or “just a bad period.”
The fact that there is so little understanding of just how bad the symptoms of menstrual health conditions are, can in part be traced back to the lack of education people receive on this at school. Research from a 2022 study in the UK showed how little focus there still is on ‘lived experience’ within menstrual health education, revealing that just 14% of lessons cover this compared to biology (56%) and provision of menstrual products (40%).
This data highlights that children and teens aren’t being equipped with enough information regarding different menstrual health conditions or what symptoms they might face, the impact they can have on their ability to function day to day and how to handle them. It’s vital to drive awareness that not everyone will experience periods in the same way and not everyone is starting from the same place when it comes to their menstrual health. Millions of people are living with symptoms that impact their daily lives and prevent them being able to work, enjoy a social life or contribute as they would like to their community.
Assuming that all periods are broadly the same puts those living with menstrual health conditions at a severe health disadvantage. It delays access to specialists, lengthens diagnosis timeframes and puts off treatments that could improve symptoms. It can also exacerbate the problem and lead to additional health problems including mental health issues. People living with menstrual health conditions need different products, different tools and different access to healthcare to live their lives to the fullest, than those whose periods don’t impact their daily lives. Menstrual equity is key in the fight for genuine gender equality.
Education and understanding are the tip of the iceberg when it comes to menstrual equity and there is a long way to go before it even starts to get the investment, research and attention it truly deserves. Menstrual health was defined in a recent research paper as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in relation to the menstrual cycle.” Until such a day that every person who menstruates is enjoying their best menstrual wellbeing, menstruation will continue to impact people’s ability to participate in society and live their lives to the fullest, and gender equality will remain a far-off dream.