The Heart of Sexism: An Exploration of Gender Bias in Cardiovascular Care
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“Analysis of UK statistics estimates that between 2003 and 2013, more than 8,200 women died from myocardial infarctions that could have been effectively treated if they were only given the same quality of care as men.”
The problem is clear, “cardiovascular disease is the number one risk factor for death in women” and yet, women continue to be misdiagnosed and undertreated in both the primary and acute care settings, according to the department of cardiovascular surgery at Columbia University (The mounting crisis). As a result, women around the world are dying unnecessarily from treatable cardiovascular disease. Analysis of UK statistics estimates that between 2003 and 2013, more than 8,200 women died from myocardial infarctions that could have been effectively treated if they were only given the same quality of care as men (Leeds, 2018). This analysis will explore three factors relating to sexism that contribute to the mismanagement of female cardiovascular health: cultural stigmatization of women’s pain, gender-based socialization around pain perception and reporting, and physician bias.
A women’s pain: Is it all in her head?
The historical context of sexism in healthcare is one of stigma and dismissal towards feminine pain and other health symptoms. Throughout history, female pain was considered the result of psychological imbalance, with labels such as hysteria being a common explanation for physical symptoms with no apparent physical cause. It was in 1980 however that this dismissal of female pain was officially codified into the medical literature. The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3 included the diagnosis of Somatization Disorder which was characterized by vague symptoms such as painful, irregular periods, loss of interest in sex, pain in the stomach or chest. While somatization disorder “acknowledged the intricate ways that the mind can express itself through the body…it clinically legitimized so many damaging myths…about women’s excessive emotional relationship to illness” and quickly became the diagnosis of least resistance when a physician could not elucidate an organic physical cause for a woman’s illness (Cleghorn, 2021). This trend continues today, and while somatization disorder has fallen out of vogue, it has been easily replaced by other, equally vague psychological diagnoses such as anxiety, depression, and borderline personality disorder (a condition characterized by self-destructive behavior and disordered attachment patterns often related to early life trauma).
Socialization around pain perception and pain reporting puts women in an intolerable double bind. Research indicates that female children are socialized to be more sensitive to, and expressive of, pain. Social priming around pain expectations also seems to shift female pain reporting behaviors, such that people scoring higher on measures of femininity were also likely to score higher on levels of pain sensitivity when primed with the expectation that women have a lower pain threshold than men (Samulowitz et al., 2019). Incidentally, the effect disappeared when social priming was discontinued. However, this entrainment to express and report pain differently than men leads to unhelpful stereotypes around female pain in the healthcare setting. In a systematic review of gender bias as it relates to physician impression of female patients, women were classified as reporting more pain, fabricating pain, and reporting pain that was all in their heads. It was also found that women with unexplained pain were more likely to be assigned psychological than physical causes for their pain. Regarding the treatment of said pain, more women reported bring “mistrusted or psychoanalyzed by their healthcare providers,” prescribed “less effective pain relief,” and offered more antidepressants and less opioid pain relief as compared to men (Samulowitz et al., 2019).
Physician Bias: Killing women, literally
While physician bias impacts every subdiscipline of healthcare, it is particularly insidious and deleterious in cardiac care. A 2015 review found that while biology is likely responsible for gender differences in pathophysiology and clinical presentation between men and women with cardiovascular disease, it is physician bias that accounts for gender differences between preventative interventions, diagnostic strategies, management of acute coronary syndromes, response to therapies, and adverse outcomes. For example, women with decompensated heart failure are hospitalized at a rate proportional to their male counterparts but receive “fewer evidence-based therapies and less optimal doses of such therapies” (Wenger, 2012). In addition, a 2018 study found that women were less likely to survive an acute cardiac event when treated by a male physician than when treated by a female physician (Greenwood et al., 2018). Unfortunately, gender bias extends to the primary or preventative care setting as well. “Only 40% of women reported having a heart health assessment at their annual wellness exams [and] of the 74% of women who had a least one risk factor for heart disease, only 16% were told by their doctor that they were at risk” (The mounting risk). As long as physicians continue to dismiss female reports of pain, underdiagnose, and undertreat chest pain, and underappreciate risk for CVD in at-risk women, heart disease will continue to be the number one killer of women in the United States.
We often conceptualize gender bias in healthcare as a nuisance, and artifact of healthcare’s patriarchal etiology. Something to be bothered by, but not necessarily feared. On the contrary, this brief exploration makes clear that sexism, the dismissal, and stigmatization of female pain is not just an annoyance, but a deadly inaccuracy. Sexism kills. It does so in subtle and overt ways in all corners of society, including every aspect of healthcare. Cardiac care is simply one of the most stark and deadly examples. As we move to the future, it is essential that we continue to recognize the sexist origins of healthcare, the perturbed relationship between female socialization around, and provider perception of, female pain, and the deadly physician bias gatekeeping adequate preventative and acute care.
References
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