Jules Montague is a consultant neurologist at the Royal Free London NHS Foundation Trust, and an honorary consultant neurologist at the National Hospital for Neurology and Neurosurgery, Queen Square
Monday 11 January 2016 18.35 GMT
This week, the Brain Tumour Charity reported that women with brain tumours are being dismissed as attention-seekers or told they are just tired – only getting a diagnosis after several trips to the doctor. This delay can be catastrophic.
But it is perhaps unsurprising. Historically, women’s health has been viewed with a “bikini approach”, the primary focus being breasts and the reproductive system. Cardiologist Nanette K Wenger notes that heart disease, for example, is perceived as a man’s disease. A 1960s conference hosted by the American Heart Association in Oregon on women and cardiovascular disease was entitled: “How Can I Help My Husband Cope with Heart Disease?”
Accepting this gender-uniform model of disease has repercussions. One study drew data from 35,875 cardiac patients, 41% of them women, across nearly 400 US hospitals. It found that women faced a higher risk of dying in hospital, subsequent heart attacks, heart failure, and stroke. They were less likely to have an ECG within 10 minutes and to receive crucial medications. And women younger than 65 years old are more than twice as likely to die from a heart attack than men of the same age.
There is more complexity to this than mere gender bias. Women tend to present to hospital later and with atypical symptoms. Being a smoker and having diabetes seems to confer more cardiac risk for women than men. There are biological differences that could explain differential responses to drugs. Clinical trials give us answers for men that have simply been extrapolated to women. But women are also more likely to have their symptoms attributed to depression and anxiety, with a failure to recognise that men and women respond differently, at least in some conditions, at molecular, genetic, and cellular levels.
It’s not just cardiac issues that are underdiagnosed in women. For every girl diagnosed with autism, four boys are diagnosed with the same condition. Are we missing the diagnosis in females? It’s easier to detect in boys: perhaps because we look harder for it, expect it more, and because our diagnostic criteria were designed for detection in boys. Attention deficit hyperactivity disorder also seems to present differently in females. Women with ADHD tend to be less hyperactive and impulsive, more disorganised, scattered, forgetful, and introverted. Gender disparity in diagnosis extends to cancer, too. Each year in the UK, approximately 700 women with bladder or kidney cancer experience delayed diagnosis. It takes longer to get referred to a specialist, even when presenting with exactly the same symptoms as men. One publication, The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain, found that women were less likely to receive aggressive treatment when diagnosed, and were more likely to have their pain characterised as “emotional,” “psychogenic” and therefore “not real.”
Does this mean men have it good? Of course not: men face delayed diagnoses in conditions such as breast cancer for a start, and overall are 35% more likely to die from cancer.
This is not a competition, though. Gender disparity in either direction needs to go. Time to banish the bikini approach for good.