Medical gender wars

First came the whining feminists. Next, the inevitable male backlash. Health research has become a casualty of the battle between the sexes.

Published September 20, 2000 7:00PM (EDT)

On the way to Las Vegas to collect his Teamsters endorsement on Monday, Al Gore made a stop at the University of Nevada at Las Vegas to deliver his latest smarmy valentine to the female voter. In an appearance at a women's health event, Gore pledged to fight for legislation that would give new protections to women enrolled in managed-care plans, forcing HMOs to pay for mastectomies, routine OB/GYN services and hospital stays of at least 48 hours for breast cancer surgery.

Women's healthcare, on the face of it, looks like the kind of motherhood-and-apple-pie cause that no reasonable or decent person could oppose. It probably has more bipartisan support than any other "women's issue." Eager to woo women back, the Bush campaign is also portraying George W. as the real women's health champion, pointing out that as governor of Texas he signed into law many of the same benefits Gore is now promising. But this seemingly wholesome women's crusade has a dark underside. It has used fictions and half-truths to polarize the sexes and promote fear and resentment among women. Combining elements of radical feminism and traditional paternalism, it has turned healthcare into a battleground for gender politics in which men, too, are now vying for the title of victim.

For one thing, the women's health movement, which became an influential political force in the early 1990s, is based on a myth. The myth is that, until this movement rode to the rescue, women were the victims of what feminist wags like Leslie Laurence and Beth Weinhouse call "medical mal(e)-practice" -- systematic abuse and neglect by a patriarchal medical establishment.

This fiction flourishes not only in the literature of advocacy groups ("medical research has mainly been done on men, for the benefit of men only," proclaimed the National Women's Health Network in 1994), but in the media and in political rhetoric. At a Women for Gore rally last year, the vice president not only pledged that "women's health will always be at the top of my agenda" but proudly spoke of his long record of fighting for "more research funds for those diseases so recently considered less important because they befell only women, such as breast cancer."

Eight years ago, Al Gore's boss was riding the same bandwagon. "Women have had their particular concerns grossly underfunded," candidate Bill Clinton declared during a campaign stop at a Chicago hospital, citing breast cancer as "the most obvious [and] the most painful" example of this inequity.

In fact, breast cancer was one of the most extensively studied and most generously funded diseases even before the rise of women's health activism. In 1991, the National Cancer Institute gave more research dollars to breast cancer than to any other single type of cancer -- more, in fact, than to lung cancer (the leading equal-opportunity killer) and prostate cancer combined.

From 1981 to 1991, the NCI spent $658 million on breast cancer research and $113 million on prostate cancer. Medline, the comprehensive database of medical journals, has nearly 18,000 entries for breast cancer in 1966-1991, compared to fewer than 1,800 for prostate cancer and about 8,600 for lung cancer.

But who needs to bother with such facts when you've got a good theory? In 1990, as the Congressional Women's Caucus declared war on male bias in medicine, now-retired Rep. Patricia Schroeder explained, "I've had a theory that you fund what you fear. When you have a male-dominated group of researchers, they are more worried about prostate cancer than breast cancer."

The Women's Caucus, by the way, was especially incensed by a government report showing that less than 14 percent of the money spent by the National Institutes of Health in 1987 went to research on female-specific illnesses. What the congresswomen forgot to mention was that fewer than 7 percent of the NIH budget was allocated to male-specific problems, while the bulk of the money was spent on studying the far more numerous diseases that afflict both sexes.

But isn't it true that those diseases were studied almost exclusively in men, with the male body used as the norm and women routinely left out of research? Actually, no. In "PC, M.D.: How Political Correctness is Corrupting Medicine," to be published by Basic Books in January, psychiatrist and Yale School of Medicine lecturer Sally Satel reports that in 1979, the earliest year for which such data could be found, 268 of the 293 NIH-funded clinical trials included both male and female subjects -- and of the remaining 25 studies, 13 had only women.

A quick analysis of medical literature shows a fairly similar picture: More than two-thirds of all studies and trials listed on Medline in the 1970s and '80s included both men and women, while more than half of the single-sex studies were female-only. There were more all-female than all-male studies of chemotherapy, diabetes and kidney disease. Nearly 90 percent of studies of stroke and most trials of treatment for hypertension included women. Women were also well-represented in cancer research; in the early 1970s, they outnumbered men by 2,000 in a major national study on body iron levels and cancer risk published in the New England Journal of Medicine.

One area in which women's "exclusion" has drawn especially harsh criticism is heart disease research. A particularly infamous study in the 1980s investigated the benefits of aspirin for heart attack prevention in an all-male sample of 22,000 doctors. Yet many experts, including Dr. Lynn Rosenberg, a Boston University epidemiologist who has done a number of studies on women's health, believe that it made scientific sense to do such a trial and then decide if a similar study was needed for women. When studying heart attack prevention, you get faster and better results from a group in which a fairly high rate of heart attacks can be expected. Before 65, men suffer heart attacks three times as often as women (and even between 65 and 74, the ratio is 2-to-1). A reliable study that included women would have required a longer time and a much larger sample.

In addition, why shouldn't serious heart disease in middle age, when men are primarily the ones affected, be a legitimately higher priority than heart disease among the elderly? (Just as the fact that breast cancer generally strikes at a younger age than prostate cancer justifies some of the disparity in resources). Thus, the claim that women have been "left out" of heart disease research is a gross exaggeration.

The pioneering study of cardiovascular health, the Framingham Heart Study, followed a sample that began with 2,336 men and 2,873 women in 1948. The Nurses' Health Study, launched in 1976 with 100,000 women, yielded important findings on how women's hearts are affected by smoking, oral contraceptives, hormone therapy and aspirin. The nurses' aspirin study, conducted around the same time as the infamous all-male doctors' study, was less rigorous -- the nurses recorded their own aspirin intake while the doctors were randomly assigned to a treatment or placebo group -- but hardly negligible.

An analysis published in the Journal of the American Medical Association in 1992 found that women made up only 20 percent of subjects in clinical trials of treatments for heart disease. Again, this number is not as low as it may seem, given the sex ratio among patients under 65. (Older people of either sex are rarely included in drug trials because of their frailty and coexisting illnesses.) Nor was a "male model" mindlessly applied to women: Sex differences in the outcomes of surgery and drug therapy for heart patients were already being studied in the 1970s.

There is no doubt that the perception of heart disease as a "man's disease" has sometimes caused women's symptoms to be neglected -- not only by doctors but by women themselves. Overall, though, studies do not support the charge that women are less likely than men to receive aggressive tests and treatments, such as angioplasty or coronary bypass grafts, when it's warranted by their condition. (If anything, there is evidence that men at low risk are often subjected to unnecessary invasive procedures.) And vital statistics certainly do not suggest that women have failed to benefit from medical advances against heart disease. From 1970 to 1989, according to the National Center for Health Statistics, mortality from cardiovascular illnesses fell by 29 percent for men and 26 percent for women -- a minuscule difference, probably due mostly to the decreasing gender gaps in smoking and other risky behaviors.

Another myth is that nearly all drug testing until recently was done on men. True, from 1977 to 1993, Food and Drug Administration guidelines barred women of childbearing age from the early and most dangerous stages of drug trials, with an exception for life-threatening illnesses. (These rules were enacted in the wake of publicity over vaginal cancer in women whose mothers had taken DES while pregnant.) However, women participated in later stages of trials, when drugs are tested for efficacy and minor side effects, and their long-term use is monitored in larger samples. Indeed, the guidelines specifically required drugs to be studied in the groups that would use them; FDA surveys in 1983 and 1988 found that "both sexes had substantial representation ... in proportions that usually reflected the prevalence of the disease in the sex and age groups included in the trials."

This is not to say that medical research hasn't had some blind spots where women are concerned, particularly in areas stereotyped as male. Thus, studies of alcoholism have disproportionately focused on men. AIDS is another area where female-specific problems initially received too little attention. By the mid-1990s, though, women were actually overrepresented in NIH-funded AIDS clinical trials: They made up more than 30 percent of the subjects, even though they accounted for about 12 percent of AIDS cases, according to Satel's research.

To further their cause and whip up the indignation of the woman in the street, women's health advocates have relied on a number of bizarre claims. Sen. Olympia Snowe, R-Maine, has repeatedly asserted that until she and her female colleagues intervened, even breast cancer studies were conducted on men. Former NIH director Bernadine Healy told the Ladies' Home Journal in 1997, "There may be no better example of gender bias in the annals of medicine than the neglect of STDs in women." In fact, a Medline search shows that of the articles on sexually transmitted diseases in medical literature in 1966-1990, 12 percent dealt only with men and 20 percent only with women.

What's more, with some activists, "patriarchal medicine" can't win no matter what it does. First, male doctors are accused of doing too many hysterectomies and gratuitously cutting up women's bodies. (While hysterectomies are far more common in the U.S. than in Western Europe, this difference seems to reflect less gender bias than the overall scalpel-happy attitude of American physicians; it is just as stark with regard to male-specific surgical procedures like prostatectomy.) As a result, HMOs try to curb questionable hysterectomies and are accused of denying care to women. First, a highly politicized breast cancer movement claims that a terrible disease that affects only women has been neglected. Then, in 1999, a women's health exhibit at the Maryland Science Center blames our society's fixation on breasts as a "symbol of women's sexual desirability" for a disproportionate focus on breast cancer to the exclusion of some other diseases that pose a greater threat to women.

Even when a May 2000 report from the General Accounting Office showed that women substantially outnumbered men in NIH-funded clinical research -- they made up 62 percent of all participants and only 29 percent those enrolled in cancer studies -- women's advocates and the media managed to put a women-as-victims spin on this news. "Government-Funded Studies Deny Women Key Health Data," read the headline on a USA Today editorial, which focused on the fact that not enough study findings were being broken down by sex. Yet Satel argues, as do many other experts, that meaningful clinical sex differences are surprisingly few and that analyzing all medical data by gender would raise research costs to truly prohibitive levels.

The politics of women's health may have skewed some priorities. In 1997, when a National Cancer Institute panel challenged the standard recommendation of annual mammograms for all women in their 40s and suggested that each woman should make the decision for herself in consultation with her doctor, an uproar ensued -- partly due to perceptions that the medical uncertainty was a result of shortchanging women. "If this was a health problem unique to men, would more money have been spent trying to figure out how to detect it and what to do about it?" inquired Dee Dee Myers on CNBC's Equal Time. The Senate quickly held hearings and voted 98-0 ("on the basis of some mysteriously acquired epidemiological insight," Washington Post columnist Jessica Mathews noted wryly) for a resolution criticizing the NCI report and affirming the benefits of early mammography. By the way, just a month later, a similar medical debate on prostate cancer screening for men over 40 went virtually unnoticed by the media or by politicians.

What's more, due to the pressure from women's health activists, men are now the ones who are getting short-shrifted, as the latest NIH data indicate. A men's health movement has already mobilized in response; organizations like the Men's Health Network, Men's Health America and several prostate cancer activist groups have tried to imitate the women's tactics. Over the past few years, they have achieved some success in boosting funds for prostate cancer research, with the help of famous survivors like Bob Dole and Gen. Norman Schwarzkopf. In June, Rep. Duke Cunningham, R-Calif., and Sen. Strom Thurmond, R-S.C., introduced the Men's Health Act of 2000, which would establish an Office of Men's Health within the Department of Health and Human Services as a counterpart to the existing Office of Women's Health -- though Congress hasn't shown much enthusiasm for the idea.

Some men's health advocacy groups make their own share of dubious claims -- for instance, that the six-year gender gap in life expectancy is due to medical neglect of men rather than biology. (While it's true that women's greater longevity did not manifest itself before this century, this was primary due to women's early deaths from childbirth and infectious diseases.)

But when the discussion of medical issues is taken over by the gender warriors fighting over a cut of the pie, one can expect some shrill rhetoric from both sides.

Now, we have Al Gore and George W. Bush trying to outdo each other in offering health privileges to women. But why do women recovering from breast surgery deserve more protection and consideration than men recovering from prostate surgery, or better yet, colon cancer patients of either sex?

Long before feminism, there is little doubt that most men were concerned about the health of their mothers, wives, sisters and daughters. (If anything, in the last few centuries, the Western brand of patriarchy included the view that women deserve greater protection from harm than men -- which may explain why so many politicos of all ideological stripes have so easily jumped on the women's health bandwagon.) Today, women who are concerned with women's rights are usually also concerned about the health of fathers, husbands, brothers and sons. At the risk of sounding corny, it's time to stop playing gender politics with medicine and to redirect our energy toward providing better care for everyone, regardless of their sex.

By Cathy Young

Cathy Young is the author of "Ceasefire! Why Women and Men Must Join Forces to Achieve True Equality."

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Al Gore Breast Cancer Gender Healthcare Reform