Behavioral Medicine Lecture 13

2) Gender

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Women are not men

Bikini approach

Research on women tend to have a bikini approach of breasts and pubic area

Heart disease and women

Under 10% of research has included data on women

Some not-so-fun facts

• In 1977 the FDA banned most women of “childbearing potential” from participating in clinical research studies, concerned that hormone levels would muddy results

  • 1993 that Congress codified a new NIH inclusion policy for women and minorities into law

  • As of 2020, only 10.8% (NIH) funding is allocated to women’s research

  • Despite living longer than men, women spend 25% more of their lives in poor health

(cont)

• 2024: analysis of common medical interventions, 64% were found to disadvantage women due to lower effectiveness, access or both.

• WHO estimates that 1/10 women worldwide are living with endometriosis

  • Getting a proper endometriosis diagnosis can take up to 11 years.

  • Analyses of US health records and studies indicate that fewer than half of women living with endometriosis have a documented diagnosis

Frued

• Freud coined the term hysterical 

  • He believed that women overexaggerated pain or had psychosomatic pain

(cont 2)

• 2016: Review of 112 internal-medicine residency programs found:

  • ~25% did not include menopause in the core curriculum,

  • ~70% did not include infertility,

  • ~ 30% did not include contraception

  • ~40% did not include PCOS (which affects ~13% of women).9

• 2021: study showed that in 75% of cases where a disease impacts one gender, the research funding patterns favor men.

  • Diseases that predominantly affect women, e.g. migraines, headaches, anorexia and endometriosis, received funding that was a fraction of what was awarded for diseases that predominantly affected men, when funding amounts are matched to disease burden

• 2X the funding goes to diseases that affect men vs. those that mainly impact women

(cont 3)

• 1999: The American Heart Association published a Guide to Preventive Cardiology for Women finally recognizing that women experience heart disease (including heart attacks) differently.

  • Only 4.5% of funding for coronary artery disease research is targeted at women.

  • Cardiovascular disease is the leading cause of death in women; ~45 % of women 20 yrs old + are living with some form of cardiovascular disease

• Women’s health gap amounts to 75 million years of life lost due to poor health or early death every single year.

  • Closing the gap would give the 3.9 billion women in the world an extra seven healthy days a year (or an average of 500 days over the course of a lifetime)

Research in women’s health primarily focuses on diseases with high mortality, overlooking diseases leading to disability

• Endometriosis is a chronic inflammatory disorder in which women may experience debilitating chronic pain, infertility, and decreased health-related quality of life. While patients are waiting for a diagnosis, they can experience disease progression, onset of new symptoms, further decline in quality of life, and increasing health care costs

• When women get diagnosed, it is much later in the disease process, which leads to treatment being more expensive

More information re Women’s Health

• The Society for Women’s Health research found here:

• Founded 35 years ago to address disparities in women’s health

• Mission: Advance women’s health through science, policy, and education while promoting research on sex differences to optimize women’s health.

• Vision: Make women’s health mainstream

Women pain

• When women are in pain, it tends to be downplayed

• In terms of gender stereotypes, men are viewed as rational, while women are viewed as irrational

• *video on slides

• Women talking about how their conditions were initially dismissed, and then diagnosed with a severe condition later

Why is women’s pain not taken seriously

• sensitive to it BUT their reports are taken less seriously & receive less aggressive treatment

  • e.g. sedatives vs. pain medications

WHY?

• Women have more coping mechanisms to deal with pain but this may suggest that they can tolerate it better and that their pain does not need to be taken as seriously

  • i.e. women continue to complete tasks in her day-to-day life, vs. men who stop when in pain

• Halo effect “What is strong is beautiful”: More attractive patients (vs. unattractive patients) are viewed as experiencing less pain

  • Women are socialized to attend more to their physical appearance = more often a victim of these assumptions

(cont)

• Because of childbirth, women are thought to be able to tolerate higher levels of pain and therefore need less treatment for it

• Women more frequently report pain to a health-care provider but are more likely to have it discounted as "emotional” or "not real.”

  • Freud & conversion hysteria with Anna O.

  • The male gender role is associated with strength and emotional inhibition vs. the female gender role which encourages the expression of emotion.

  • The subjective nature of pain requires health care providers to view the patient as credible and objective; “emotional” stereotype is at odds with these qualities

Women & pain

• S1: participants

  • 981 (65% women) ER patients presenting with abdominal pain

  • Triage pain score (1–10), patient demographics, provider gender, and final ED outcome were recorded by RAs

  • The type/time of medications administered were obtained directly from the medical record

• DV:

• Time to analgesia: time from patient placement to time of analgesia administration

• Type of analgesia administered: opioid or not

Results

• Analgesia was administered to 62% of the study group.

• Compared to men, women had a similar mean pain score (6.7 vs. 6.5; p = 0.3), but were significantly less likely to receive any analgesia (60% vs. 67%), and less likely to receive opiates

• Women who did receive analgesia waited, on average, 16 minutes longer for their medication than men (median time 65 minutes vs. 49 minutes)

  • For opiates, 63 minutes vs. 48 minutes, difference 15mins

• This gender disparity in receipt of opioid analgesia existed regardless of attending or resident gender, suggesting an implicit bias

Women & pain

• Schäfer et al., 2016

• Effects of trustworthiness, patient gender, and patient history of depression on pain clinicians’ and medical students’ views of patients with chronic pain

• 34 pain clinicians and 29 medical students watched videos and used a scale to rate the extent they believed the patient was exaggerating/hiding/minimizing pain, and the likelihood that they would prescribe certain treatment

• Men were seen as experiencing more pain than women, and more likely to be hiding or minimizing their pain, while women were seen as more likely to be exaggerating pain

  • True for both pain clinicians and medical students, but much more pronounced for medical students

Women & pain (cont)

• Pain doctors and students were more likely to prescribe opioids and non-opioid analgesics to men than women, and these judgements were unrelated to the participants’ pain estimates

• Trustworthiness perceptions had no effect on men’s pain estimates,

  • BUT women who were perceived to be untrustworthy were attributed less pain than those perceived to be trustworthy

Beyond doctor’s perceptions

• Zhang et al 2021

• Experiment 2:

  • 197 participants reviewed video clips of men and women discussing their chronic shoulder pain

  • These videos were coded for pain expressiveness and self-reports of pain

  • DV: pps ask to behave like a doctor prescribing pain treatments, psychotherapy treatments, and a forced choice between the two.

  • Pps also completed Gender Role Expectation of Pain (GREP) questionnaire

Found

• The prescribed amount of medication or therapy didn’t differed by gender of patient

• In the forced-choice condition men were prescribed medication over therapy significantly more than women

• GREP showed strong gender stereotypes:

  • Belief that men are less likely to report pain correlated with higher pain estimates/prescriptions,

  • Beliefs that women were more likely to report pain not correlated with estimates/prescriptions

Graph

• Women’s pain is underestimated compared to men’s 

• Perceived to befit more from psychotherapy

3) Gender & Race: black women & birth

“The statistics show that even if you are a Black woman with a Ph.D., the likelihood is that a white woman with a high school diploma would survive pregnancy and childbirth more than you would,”

Pregnancy-related deaths

“The average rate of 17.4 maternal deaths per 100,000 live births for all American women is disturbing, but Black women are dying more than any other racial or ethnic group. The widest disparity is seen when compared with white women, where Black women are 2/3 x more likely to die of pregnancy-related causes. They are also more likely than white women to experience severe maternal morbidity, also known as “near misses.” [..] “Structural racism is a powerful social determinant of maternal health [..] and persists today in more subtle healthcare policies and practices.”

video on slides

• Mortality rates during childbirth among black women is 2.6 times higher than white women

• Childbirth mortality rate jumped 30% from 2020 to 2021

• The US is the 99th ranked country in black mortality during childbirth

Serena Williams

Despite her obvious strength and good health, the world champion tennis player has a history of blood clots. [..] Williams takes blood thinners every day to prevent clots from forming. After the C-section, though, she stopped taking them to allow the surgical wound to heal. The next day, off the “anticoagulant regimen” medication, the 23-time Grand Slam winner began to gasp as she recovered in her hospital room. Not wanting to worry her visiting mother, Williams stepped into the hall and flagged a nearby nurse, insisting that she needed an IV with heparin, a blood thinner, and a CT scan to check for clots. The nurse believed that medications might have befuddled Williams, Vogue says, but a doctor arrived – only to perform an ultrasound, and not the CT scan that Williams believed she needed. The ultrasound revealed nothing, and […]Williams reiterated: “I told you, I need a CT scan and a heparin drip.” Obeying her request for the scan, the medical team found several small blood clots in her lungs and immediately began the medication.”

Black women are more likely than black men to say the healthcare system holds black people back

4) Obesity Bias

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Obesity and evolution

• Evolutionary basis to eating & weight-regulation

  • During pre-historic times inconsistent food supplies were one of the main threats to survival

  • Fittest individuals = preferred high calorie food (taste preferences), ate to capacity when food was available, efficient body-fat storage metabolism

  • Evolved strong mechanisms to start eating & weaker ones to stop eating

Current society

• Retained prehistoric food preferences but food no longer requires tremendous energy expenditure

• Cultural factors contribute to the centrality of high calorie

Fat cells and fat loss

• The average human can have between 10 to 30 billion fat cells.

  • Cells are called “adipocyte” cells and store non-consumed fat as triglycerides.

  • Insulin (energy storage hormone) regulates the flow of triglycerides into your fat cells

  • Number of fat cells set during adolescence and levels off into adulthood

  • If you are an obese child, you will add twice as many fat cells compared to a child of average weight as you mature.

  • Fat cells shrink when you lose weight because of an energy deficit and your body's release of waste products.

Obesity and stigma

• Weight stigma is the devaluation of an individual or group due to weight or body size

  • Affects up to 57% of all persons regardless of body size

• People labeled as obese are more stigmatized than any other social group

  • Stereotypes of being lazy, weak-willed, unsuccessful, unintelligent, lacking self-discipline, and noncompliant with self-care and weight loss recommendations

  • Negative stereotypes often dictate healthcare provider’s behaviors (discrimination)

Fat and Stigma

• Many significant contributors to obesity are beyond genetic/biological factors and are also beyond individuals’ control

  • Social disadvantages may increase obesity through chronic stress, anxiety, and negative mood – all are associated with abdominal obesity

  • Activating physiological mechanisms that can increase appetite and blunt the satiety system, increasing fat retention & food intake

• ‘‘a more accurate conceptualization of the obesity epidemic is that people are responding to the forces in their environment, rather than lacking in willpower and self-control.” D.A. Cohen

• There is increasing consensus that environmental change is essential to the solution of obesity