Androcentric Medicine and the Curse of the Hybrid Beast

Areej Abdel-fattah, third year, looks at the issue of gender blindness in medicine.482605_10151449872582569_171966315_n

p

v

c

L'Inconnue de la Seine
L’Inconnue de la Seine

The moment you realise Rescusci-Anne was, in actuality, Rescusci-man all along, is an eye-opening one. Like a creature you might face in the Underworld, it is a hybrid beast, with the torso of a man and the hauntingly beautiful face of the ‘Inconnue’, a French woman who drowned in the Seine (Grange, 2013). This hybridisation of a female identity and a male body causes a lot of confusion, as one is led to expect the same rules to apply to females as males for any one condition. My point is, at this point in time, I would not be confident performing Basic Life Support on a female simply because I have never practised CPR on a female mannequin. And as this could potentially affect approximately half of society, I feel this matter needs to be addressed urgently.

I had difficulties telling the gender of our cadaver in second year – in the following dialogue with a group member, I tried to pick out differentiating features:

Me: Is this a male or female cadaver? I think it’s male because it has short hair… But maybe they shaved its head post-mortem…

Group member: it’s male.

Me: How do you know? Ahh! It’s flat-chested and has narrow hips, I get it.

Group member: Or, you could just look there *nods head towards genital region*”

This anecdote, which has proved a most entertaining one at family gatherings and had others in stitches at my expense, actually made me realise how non-gender-discriminative medicine can be. However, in my defence, things aren’t always as they seem, as illustrated by Dr Tello in what I thought was the most gender-identity-related-doubt-inducing lecture.

Aside from being taught the obvious differences between males and females, we are taught almost all material in a non-discriminatory fashion (with the welcome rare exception), leading to the unsound assumption that everything applies for both males and females apart from the reproductive system. As Dr Cecil wisely said to my group earlier this week; “you should never make assumptions unless you’re a trained economist” and rightly so, but stubborn person that I am, a part of me still likes to assume that even a trained economist would have arrived at the same conclusions as me had they been exposed to the same information I am exposed to. The problem stems mainly from the fact that most medical knowledge known to “man” was based on studying males, and so literature is very androcentric. Unfortunately, this tradition still persists in the modern day, with most clinical research being conducted on male subjects. (Khan, 2014)

I remember when learning to perform digital-rectal examinations in clinical skills, Dr MacLeod told us that in the past, digital-rectal examinations were a very important tool in obstetrics, used to determine how far into labour a pregnant woman was. I asked if there were female plastic models available to practise on as we had only practised on male ones, but to my disappointment, they were in storage due to there not being enough of them for all groups. One day, hopefully before I qualify, I may get the chance to see one, but for the time being, to my consolation, a plastic model is not the real thing anyway. Sophie Main, a fellow third year medical student, also drew my attention to other areas where we had not covered females properly, such as catheterisation, and told me a story about a junior doctor attempting to catheterise a female for 45 minutes because he erroneously tried to place the catheter in the patient’s clitoris.

I was surprised to learn (through Tumblr, of all sources) that females experience myocardial infarctions differently, and tend to present with symptoms that do not match the “classic presentation”. There is not enough awareness of this, even though Ischaemic Heart Disease is the leading cause of death for females in the world, well above breast cancer (see figure 1 from WHO). Recently, there was a campaign in the USA to target this, as women were not aware that they were experiencing myocardial infarctions. Sophie also drew my attention to an advertisement featuring Elizabeth Banks entitled ‘Just a Little Heart Attack’, aimed at raising public awareness of this.

Screenshot 2014-11-15 21.19.39
Figure 1: World Health Organisation Statistics

The fact that the “classic presentation” is synonymous with “male presentation” drew my attention, and I decided to delve deeper. As it turns out, females happen to have different presentations for numerous other conditions, namely: Cancer, Liver Disease, Osteoporosis, Parkinson’s Disease and Multiple Sclerosis. This can have an equally adverse effect on males as their osteoporosis is likely to go undetected. (Baggio, 2013)

Pharmacological treatment also has different effects on females than it does on males, due to differences in body composition and physiology. This means that females require different dosages, and in some cases, a different drug altogether; for example: aspirin has different effects in the prevention of heart disease and stroke in females than it does in males. The following table shows some gender discrepancies that affect pharmacological treatment:

Screenshot 2014-11-15 21.21.56

Solutions to this problem are urgently needed, but results are unfortunately not immediate. The main way to tackle this would be to include females more in clinical trials, increasing the female-centric literature available in order to reach a truly proportional representation. Altering teaching to be more gender-specific would arguably be the most effective strategy, as future doctors would be more aware of the gender gap and so more likely to address it. Increasing public awareness of female-specific presentations would also mean that conditions are detected and treated earlier. Dr Marianne Legato, an expert in Gender-Specific Medicine, said, “patients are calling for this (gender-specific teaching) but many doctors don’t want to hear about it, because it’s more work.” (Khan, 2014) The denial exhibited here is very alarming and if there is any hope that this situation will change for the better, then it will require input from all medical professionals.

REFERENCES

Baggio, Giovannella et al. (2013). Gender medicine: a task for the third millennium. Clinical Chemistry and Laboratory Medicine (CCLM). 51 (4), 713-727. http://www.degruyter.com/view/j/cclm.2013.51.issue-4/cclm-2012-0849/cclm-2012-0849.xml?format=INT Last accessed 14/11/2014.

Grange, Jeremy. (2013). Resusci Anne and L’Inconnue: The Mona Lisa of the Seine. BBC. http://www.bbc.co.uk/news/magazine-24534069. Last accessed 14/11/2014.

Khan, Holly. (2014). Sex and Medicine – It’s Time to Discriminate.Available: http://cafecommunique.org/component/easyblog/?view=entry&id=43&Itemid=290. Last accessed 14/11/2014.

Pearson, Catherine. (2013). Gender Medicine: Why We Need To Focus On How Women vs. Men Get Sick. Available: http://www.huffingtonpost.com/2013/03/27/gender-medicine_n_2956796.html#_=1365100009161id=twitter-widget-0lang=enscreen_name=HuffPostWomenshow_count=falseshow_screen_name=falsesize=m. Last accessed 14/11/2014.

Advertisements

2 thoughts on “Androcentric Medicine and the Curse of the Hybrid Beast

  1. Med Student

    Interesting article! I’m in clinical medicine at the moment having just done a research masters, so just my two cents on this.

    As far as I’m aware, here are a number of reasons why male specimens (so say animals e.g.) are used more than females for various trials. The main one is to account for confounding variables of the menstrual and reproductive cycles. Now you can counter that by saying ‘well of course women in real life have these cycles too!’ Yes, but the cycles are drastically differently timed and reproductive biology is not as translatable from animals to humans as simple reactions to other things. This is where the drug trials factor in. Unfortunately, it is androcentric but I’m a bit concerned as to whether experimenting on more female mice would actually lead to *better* data as the cycle in the animals would not translate to the cycle in women. I am however fully sympathetic to women not getting the fair share in drug dosage- however it is difficult to rectify this pre-clinically, and is usually done post-hoc. I can furthermore totally sympathize with Dr Tello’s experience as he studies reproductive biology.

    In terms of clinical models and such, one obvious factor is that women have breasts. I know it sounds sort of ‘well duh’ but it plays a big factor on what exams you can do on them- in resp e.g. we hardly auscultate from the front and the apex beat is usually inpalpable or invasive. So for clinical models and such because there is a large variation in the chest area (don’t get me wrong there is large variation in general of course!) and the fact that it’s either useless or indecent to examine in certain areas for women (in the med student stage at least) the models we have to work with tend to be male-based. I agree about the catheters though, but I assure you I’ve seen plenty of female models on placement so that shouldn’t be an issue. So this is where the CPR model comes in. The reason we have a clearly demarcated male chest is that if we had an obese person’s chest or a female one with breasts, there is too much variability to account for in general, and therefore practicing such skills would pretty much rely on observing them in clinical practice or (heaven forbid as little as possible) doing them yourself. So again we run into the ‘women have breasts’ issue as well as the ‘some people weigh more/less than others’ issue. On that note still, we do have a breast exam model at St Andrews which you’ll see next semester.

    Finally, we get to the ‘female presentation’ of symptoms. A lot of my lecturers in clinical and late pre-clinical medicine have been good about the discrimination between the two. Having said this, however, there are a lot of ‘non-classical’ presentations that are also risk factors. One that we were taught recently that pain radiating to both arms rather than one makes you like 30X more likely to be having an MI even though the ‘one arm’ is the classical thing. In my personal opinion, the ‘classical presentation’ is usually what people see the most often- more males have MIs, therefore more patients in general have the classical presentation. I think we should be wary about making this a gendered thing, but rather increase awareness of non-classical symptoms and presentations.

    In conclusion, I’m not a big fan of crumpling up research, clinical presentation, pharmacology and clinical models into one whole point of ‘let’s encourage gender-specific medicine’. I think it would be best to consider each of them in turn and then think why things are being done the way they’re done. Thanks for reading 🙂

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s