Dossier: Sexuality

Gender medicine: we’re all different

Gender influences the course of an illness, diagnosis and treatment. However, medical research and teaching have long been based on the average male patient. Things are changing now, resulting in better medical care for women, men and sexually diverse people.

Text: Jessica Braun; photo: Sanitas

A broken bone isn‘t always just a broken bone. So if an elderly man comes to hospital with a fracture, it’s better if the doctors providing treatment aren’t blinkered by gender-biased thinking. Women are five times more likely to suffer from osteoporosis than men, which means that male patients can often go undiagnosed. This can lead to disability or, in the worst case, early death.

The same also applies to infections. During the pandemic, it was shown that COVID-19 is more likely to be fatal for men, while women are more likely to suffer from long-COVID symptoms several weeks after the infection. “The pandemic has once more highlighted the need for gender-specific medical care,” says Ute Seeland, a specialist in internal medicine and chair of the Deutsche Gesellschaft für Geschlechtsspezifische Medizin (German Society for Gender-Specific Medicine).  

Typical patient: 45 years old, 75 kg, white and male

Male, female or intersex?

The answer to this question plays a role in how likely a person is to develop a specific illness. It influences the symptoms they may have and which treatments are most likely to succeed. However, this went unnoticed in medical research and teaching for a long time, because the world of medicine is largely male-dominated: labs mainly use male mice and rats for basic research, drug trials predominantly choose men as test persons, and leading posts in companies and universities have traditionally been held by men. Ute Seeland says that the typical patient studied throughout her training was 45 years old, 75 kg, white and male.

Our upbringing, education and social position can influence the development and course of a disease

A woman is not a small man

Men have a higher percentage of water in their bodies, whereas women have more body fat and a slower metabolism. These and other factors have an impact, for example, on how quickly drugs work and how high the dosage should be. As recently as 2013, the US Food and Drug Administration had to ask several sleeping pill manufacturers to halve their dosage recommendation for women due to an increase in morning traffic accidents.

In the meantime, up to 9,000 articles are published each year highlighting the fact that the differences go all the way to cellular level. “Sex chromosomes are responsible, among other things, for the development of the sex organs. These produce hormones, which in turn control processes in the body,” says Seeland. Recent studies show that even at the cellular level not all processes are gender-neutral. For example, the receptors of female cells transmitted pain signals faster in animal experiments.

Gender-sensitive medicine takes these biological aspects into account even in basic research. But it goes one step further: It looks at the social gender, i.e. how a person sees him or herself, how they are seen by others and how they are influenced by their environment. “Our upbringing, education and social position can influence the development and course of a disease,” says Seeland. COVID-19 is a good example of this. At the start of the pandemic, more women were infected by the virus. This could be because more women work as carers or in retail, where it’s not possible to work from home, and they use public transport more often.  

Thalidomide scandal

There are several reasons why women are under-represented in drug trials: Their hormone balance changes several times throughout their life – during puberty, pregnancy and menopause. The menstrual cycle and contraceptives can also distort results.

Above all, however, pharmaceutical manufacturers want to avoid another Thalidomide scandal. In the 1950s and 1960s, miscarriages spiked after pregnant women took an anti-anxiety drug that had been classed as safe. This led to women being excluded from trials. However, this gave rise to a dilemma in the early 1990s: Taking part in clinical trials was the only way for women infected with HIV to gain access to new and more effective drugs. Since then, female participation in studies has been higher. However, the majority of participants are still male.

We’re playing catch-up where women are concerned

Gender-specific medicine isn’t just women’s medicine

Gender differences aren’t really taken into account in standard medical care. “They aren’t easy to record and analyse methodologically, because different factors merge and influence each other. A lot of research is still required,” says Ute Seeland. Because the one-size-fits-all approach is too exclusive. For example, depression is often misdiagnosed in men, because their symptoms, including aggression or pain, are often considered “atypical”. And this is reflected in the suicide rates.

“Examples like these show that gender-specific medicine isn’t just women’s medicine,” says Seeland. “We take both genders into account, but we’re playing catch-up where women are concerned.” She wants the change to start in medical training, so she advocates textbooks that focus on this issue, encourages faculties to revise their curriculum, and promotes the next generation of medical students, who are more aware of the differences.

A study into the treatment of diabetes conducted by the Cologne University Hospital shows how complex these differences can be. And gender also plays a role here. However, not the gender of the patient, but of the doctor providing treatment. The study showed that the success of the treatment depended on attentive listening and precise explanations – and female doctors scored highly in this respect.

Yentl syndrome

It would be better for women with heart disease if they were men. This was the opinion put forward by cardiologist Bernadine Healy, the first female director of the National Institute of Health in the USA, in an article published in 1991. Back then, heart disease was considered a male condition, which is why it often went unnoticed and untreated in women.

Bernadine Healy coined the term “Yentl syndrome” – taken from a short story by Isaac Singer in which a girl pretends to be a man to be able to study. “We hope that the brave and charming heroine Yentl survives,” writes Healy, “but that in time her syndrome goes on to become nothing but a quaint story.” However, fast forward 30 years, and women are still more likely to die of a heart attack than men.