5 Questions: Marcia Stefanick on better medicine for women
A Stanford professor of medicine discusses why giving consideration to sex and gender differences in research and treatment would improve medical care for everyone.
The dearth of clinical research that accounts for both the sex and gender of patients often makes it difficult for doctors to diagnose and assess treatments that would most benefit women, but the problem goes beyond that, according to Marcia Stefanick, PhD, professor of medicine at the Stanford Prevention Research Center.
She believes a deeper, overall understanding of sex and gender differences in research and treatment will result in more inclusive, and more precise, medicine for everyone.
“The system can be blind to gender bias; some disorders are considered ‘a man’s’or ‘a woman’s,’ even when both sexes suffer from them,” Stefanick noted in an article she wrote for the September issue of Scientific American. “Doctors often fail to diagnose stereotypical ‘male’ conditions in women, and vice versa, until the condition has become dangerous.”
As director and co-founder of the Stanford Women and Sex Differences in Medicine Center, Stefanick aims to raise awareness of the issue with the goal of improving health outcomes and care for everyone across the life course and gender spectrum. The center offers seed grants to encourage researchers to emphasize sex and gender in their work; provides a range of courses on sex, gender and sexuality for medical, graduate and undergraduate students; and organizes symposiums on women’s health and sex differences for the broader university community.
Stefanick pointed to work by Londa Schiebinger, PhD, a Stanford professor of history of science who has developed a project to provide methods of sex and gender analysis for scientists and engineers. Stefanick said Schiebinger and her colleagues are pilot-testing a survey tool that was designed to measure gender and hope it will replace a scale created at Stanford in the 1970s that was based on gender norms of that era.
Writer Patricia Hannon recently asked Stefanick to discuss her work to make medical research and treatment more inclusive.
Q. What do you consider the biggest challenge to ensuring that sex and gender are routinely considered as variables in biological research?
Stefanick: There is a systematic lack of recognition, and therefore interest, among basic researchers of the possible role of sex in the questions they are pursuing, and also a general lack of understanding of what “gender” is and that it is not synonymous with “sex.”
It’s crucial, for example, that the differences in the sex of chromosomes or the differences in hormone-producing glands — and hormone levels — be considered in any clinical research so that it and any resulting treatment represent both men and women.
New diagnostic tests address the divide in some research, especially with regard to identifying and treating heart disease in women, but prevention and treatment guidelines are still based primarily on research that was mostly conducted on males.
Q. What areas of medicine can most quickly benefit from a shift in focus to improve standards of care for women?
Stefanick: Raising awareness of sex differences in immunology and cancer would be of immediate benefit to women, but would also benefit a large proportion of men.
It is worth pointing out that cardiovascular medicine has been a leader in recognizing the importance of differences between women and men, particularly younger women versus their male counterparts, in specific conditions, symptoms, diagnoses and optimal treatments. Yet a large proportion of people, including physicians, still consider heart disease a “man’s disease” and do not apply the best prevention or treatment approaches for women to their female patients.
Q. You say that considering gender and sex in both research and treatment benefits everyone. How does it benefit men, and why do you think this is especially important now?
Stefanick: The more we learn about how treatments affect women differently from men, the more we also learn about the range of biological implications among men and women, as well as the “spectrum” of biological sex rather than the contrasts and differences between them.
For example, 15 percent of women who were prescribed what was at first considered the standard dose of Ambien experienced driving impairment eight hours after taking it. In addition, 3 percent of the men reported the same side effect when taking the then-standard dose of the widely prescribed sleeping medication. The side effect alerted physicians to the need to lower the dose in women, but it also indicates a need to consider how doses apply to men, as well.
The same principle applies to understanding that few diseases affect only men or only women. So the more we learn about diseases that affect one sex predominantly, the more we should learn about detecting and treating that disease in the opposite sex.
Q. You are obviously passionate about making medicine more inclusive. What drives you to be such a strong advocate for change?
Stefanick: Most scientists want to have precise and accurate information about whatever they are studying, and I don’t believe we can have this without seeking a more comprehensive understanding of sex and gender than our current, biased knowledge base.
There is plenty of evidence that men and women differ in many ways beyond reproductive function, and yet we tend to offer a one-size-fits-all medical approach. On the other hand, our societal biases overemphasize sex and gender differences in many domains that lead to biased medical practice, which is also harmful.
But beyond medicine, understanding a fuller range and spectrum of male to female biology would give us more insight into basic biology.
Q. Do you have suggestions for how women can advocate for themselves in interactions with physicians and others involved in their care?
Stefanick: Ask physicians questions about what evidence there is in women (and/or whatever age group they fall into, or if pregnant) for any diagnostic test or treatment they are about to conduct or prescribe. This would raise awareness among physicians that they probably never learned this in medical school or pursued these questions on their own.
In a nutshell, physicians assume that what they’ve learned is appropriate for most of their patients. In fact, there may be little to no information about gender differences for many of the drugs and treatments they prescribe. Physicians should think about their oath to “do no harm” in the context of what they know or do not know about how they are managing the health care of the full range of patients in their practice, particularly women, who have often not been included in clinical studies or who have not been studied across the range of their reproductive phases.
We need to raise awareness of the fact that we are not providing optimal care and may even be harming half of our patients, and also that we have many biases that lead to wrong assumptions which may be thwarting our progress in understanding basic biology.
Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu.