Author: Marek Glezerman
To remedy what he perceives as the medical profession’s neglect of the influence of gender differences in healthcare, the author of this book set out to illustrate how men and women manifest disease and respond to treatment differently, and to demonstrate how their healthcare needs may markedly diverge. The author’s expectation is that better familiarity with these differences will enable physicians to draw ‘a more complete picture that reflects the unique nature of individual people and their bodies’, and to implement ‘a unique and comprehensive diagnostic and treatment plan for each individual‘. The author, an obstetrician and gender medicine specialist, was particularly concerned about the way the results of medical research carried out in males are applied equally to the diagnosis and treatment of both genders – a situation that entrenches healthcare gender disparity and inequity. The book therefore advocates for a ‘paradigm shift in medicine’ whereby ‘different methods of diagnosis‘ are applied to the genders, and in which drug dosages take into account, not just patients’ body weights, but their gender as well (pages 43-44, 29, 17-18, 37, 98, 105 and 184).
At the root of the book’s arguments are the anatomical and physiological differences between the brains of males and females. The author assert that there is a scientific consensus for sex-based differences in several brain structures such as the amygdala, the cortex, and the hypothalamus, and that these differences are caused by the selective exposure of males to intrauterine testosterone, and to post-natal neuroplasticity. Whilst the author admits that the functional brain variations between the genders are more significant than the structural differences, he nevertheless pointed out that this is not always the case as illustrated with the example of the corpus callosum, the massive bundle of nerve fibers that connects the two hemispheres, which he pointed out is larger in females – a feature that enables women to be better at multi-tasking than males. The author explored the functional brain-driven sex differences with particular emphasis on language skills which he said develop earlier, and are better, in females, and this is partly ascribable to the bilateral hemispheric distribution of language functions in females; this difference, the author added, accounts for such observations as the faster recovery of speech after stroke in women (pages 26-27 and 63-65).
The book also explored the physiological differences between males and females outside the brain, and this assessment highlighted the many well-recognised differences between the genders, such as a 20-30% higher muscle mass, and an 8-10% height advantage, of males. The author however pointed out that, in modern times, these masculine attributes are ‘superfluous‘ and even potentially harmful, such as when they predispose to aggression and violence. On the other hand, many of the physiological differences tend to advantage women, for example, their better ‘ability to understand facial expressions…and interpret body language‘ favours them in social contexts such as in patient-doctor interactions. Other differences the author discussed are rather double-edged – conferring both benefits and detriments depending on context. The author illustrated this with examples which include the a wider range of thumb joint movement‘ in women which confers better motor skills but increases their risk of arthritis; a more efficient immune system in women which however also makes them more vulnerable to autoimmune diseases; and the larger body fat volume in females which enables them to better preserve heat but makes them more sensitive to the cold (pages 25-28, 169, 172-175 and 186-188).
Perhaps the most clinically relevant theme of the book is its exploration of the contrasting susceptibilities of the genders to different diseases, a phenomenon the author attributed to the differential influence of sex hormones. Many of the vulnerabilities the book discussed particularly disadvantage males who the author portrayed as the weaker sex and as an endangered species who, despite being ‘stronger and larger physically…are surprisingly vulnerable during the entire course of their lives’. To support this contention, he referred to the higher male liability to intrauterine malnutrition, gastric ulceration, lung diseases, strokes, diabetes, cerebral palsy, autism, and dyslexia. Men, he added, also appear to be ‘less well-equipped to cope with life crises such as illness, divorce, and financial difficulties. Women on the other hand are more likely to develop such disorders as gallstones, Takutsubo cardiomyopathy, migraine, musculoskeletal pain, fibromyalgia, and irritable bowel syndrome. Many diseases also manifest differently between the genders, and the author referred to the prominent example of heart attack pain; this is often less acute in women in whom it is more likely to radiate to the back of the neck, rather than to the jaw or left shoulder as it does in men; these differences imply that women with heart attacks present later than men, and they are more frequently misdiagnosed and mismanaged than men (pages 107-108, 35-36, 70-73, 76, 80, 96-97, 110, 121, 193-201 and 178-179).
A worrying theme of the book is the way healthcare overlooks gender differences in its assessment and management of women. In this regard, the author regretted that women are put through many unnecessary investigations, such as cardiac stress tests, SPECT scans, and faecal occult blood test, which are not as sensitive in women as they are in men. Similarly, many treatments that have been tested only in men are inappropriate and less effective in women. Concerningly, he showed how several drugs produce contrasting results between the genders. In women for example, betablockers are more likely to cause the dangerous arrhythmia torsades de pointes, and angiotensin converting inhibitors (ACEI) are less effective and less tolerated. Furthermore, cardiac stenting is less effective in females because their heart attacks frequently result from narrowing of the smaller heart arteries. With regard to pain in women, the author stressed that this responds less readily and more transiently to medications such as morphine. Along with the regrettable tendency for health practitioners to be ‘more receptive towards men’s pain’, the result is that pain in women is often under-treated (pages 103-106, 176-177, 181-182 and 120-123).
A unique perspective that the book provided is what the author termed the ‘gender aspects of doctor-patient relationships‘. Referring to the linguist Deborah Tannen, the author pointed out that language is specifically tied to gender, saying men and women speak different genderlects which significantly impact their interactions with patients. The author observed that ‘communication in different-sex pairs is more difficult than in same-sex pairs‘, but in general, female physicians tend to be more patient-centred than their male colleagues. The author attributed this female advantage to their better verbal and nonverbal communication skills, women tending to use conversations to strengthen relationships and develop shared solutions. Furthermore, he argued that female physicians adopt a less dominant and less assertive relationship with their patients; they tend to inquire more about their patients’ feelings and concerns, and ‘spend on average 10% more time with their patients’ than male physicians who are ‘especially interested in providing and receiving information…and are more concerned about status and competition in the framework of a conversation’ (pages 219-238).
Even though this book is relatively small, it covered a surprisingly wide spectrum of gender issues related to Medicine. Although the book’s focus is the clinical aspects of gender, the author built this on a helpful review of the relationship of the foetal environment to adult health, and the dual influence of genetics and epigenetics on gender differences. Whilst the book cites ample research evidence to support its contentions, much of this appears to come from animal trials raising some doubt about their relevance to humans. Large sections of the book appeared to be disproportionally allocated to explaining organ physiology and this was often not directly relevant to the subject of the book. These minor shortcomings notwithstanding, the book has documented major gender differences relating to healthcare which throw up concerns about equity and fairness in the management of female patients.
The book has exposed significant deficiencies in the approach of medicine to gender related health issues. It highlights the importance of considering gender in all stages of the patient’s journey – from history taking to therapeutic interventions. The author’s exploration of the gender differences in the patient-doctor relationship is particularly revealing and focuses attention on the communication deficits of male doctors which may contribute to poor patient satisfaction. The book therefore offers an opportunity for individual doctors and medical education to remedy these negative inclinations and biases. The book has carefully and clearly highlighted a subject of relevance to patient care and I highly recommend it to all doctors.
Publisher, Place, Year: Duckworth Overlook, London, 2016
Number of chapters: 15
Number of pages: 250
Star rating: 5