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= Gender Disparities In Medical Research = Within the medical research field, there exists a disparity between the amount of data pertaining to women’s health as opposed to men’s health. Not only does this have major health consequences for women, but it also underscores the prevalence of gender disparities that still pervade society and academic research. In addition to a long history of bias against women in the medical field, women are still vastly underrepresented as subjects in research studies. Women are also particularly underrepresented in a number of critical areas of research, including but not limited to cardiovascular health, AIDS, and lung cancer. These health concerns are exacerbated by the risk that improper treatments, medications, and dosages are prescribed to women as a result of gender inequality and lack of female representation in research practices and subject pools.

The History of Bias Against Women Researchers and Subjects
Gender bias in the field of medical research exists in two forms: bias against women as researchers, and bias against women as subjects. Discrimination against female researchers has substantial historical background. Two main factors contribute to the significant discrimination against women in the field of research. First, is simply the traditional view and role of women. Traditional views associate women with motherhood and homemaking. As such, entering the medical research field directly contrasts historical societal norms. Furthermore, public opinion has long viewed women as less proficient in math and science, the two fields central to medical research. Of those women who have defied the expected odds, most are pushed into more ‘female’ areas of medical work: nutrition and botany (Keville, 1994, p. 18). Even today, more female doctors pursue careers in pediatrics and psychiatry than surgery (Jefferson, 2015).

By the late 19th century, more women began to earn college degrees. At this time, women’s historical role as caregivers was viewed as a threat by male physicians. If a female wanted to pursue a professional career, medicine was a natural fit: “the idea of women attending to other women appealed to the traditional Victorian ideas of modesty” (Keville, 1994, p. 19). In response to the growing female participation in medicine, medical establishments began excluding females from medical schools and crucial professional societies. Moreover, although some women have succeeded in medicine, their work is often devalued. As a result, many women have been discouraged from entering the medical field. As such, male dominance in the field of biomedical research has had a direct effect on the direction of research, which has been predominantly male-focused. Women’s health issues are largely overlooked in terms of research. When female research is conducted, it is usually in a marginal area that is of interest to men, such as birth control (Keville, 1994, p. 19).

Women have long been excluded from subject pools for clinical trials. However, in the 1980’s The United States Public Health Service formed a task force on women’s health issues. A formal report declaring that the lack of data on women was detrimental to fully understanding female health was filed in 1985 (Keville, 1994, p. 21). In 1993, the National Institutes of Health mandated that women and minorities be included in all government funded health research (Westervelt, 2015). Although this, and other efforts have improved female representation as subjects in biomedical research, gender bias is still prevalent. Such biases exist in areas such as subject pools and financial funding for women’s health issues.

Disparities Between Men and Women as Subjects
Although the U.S. has made some strides in requiring clinical trials to include more female subjects, gender disparities in research remain. For example, women are still underrepresented in clinical trials in heart disease and cancer, the primary and secondary leading causes of death of men and women in the U.S., respectively. Further, in a 2010 report from the Institute of Medicine, analysts noted that enforcement of the requirements for including a sufficient subject pool of women in clinical trials was inadequate (Mazure and Jones, 2015, p. 2). The reasons for historically excluding women from clinical trials include concerns about exposure to risk during childbearing years; misconceptions among some medical professionals that women are less affected by disorders or diseases than men and that women respond to treatment in the same way as men; and the perception that the inclusion of women in studies incurs greater costs and requires a more complex analytical design (Mazure and Jones, 2015, p. 11).

Additionally, there remains the failure of researchers to consider the influence of sex and gender in studies that do include both men and women. To illustrate, male laboratory animals are often preferred over females, yet studies do not take into account how cells may differ on the basis of sex. This is a significant finding because sexual genotype “can affect the pathophysiology and prevalence of some diseases,” and scientists are increasingly discovering that the physiological differences between the sexes are vastly understated (Mazure and Jones, 2015, p. 2-8). Further, in a review of clinical trials assessing depression treatment and development, it was discovered that “of 150 randomized clinical trials published in 2007, with women averaging 56 % of the enrolled volunteers, half the studies did not analyze results by gender. Of 768 ongoing clinical trials, 89% reported recruiting both women and men, but investigators reported an intention to analyze the results by gender in less than 1 % of these studies.” This failure to conduct gender-specific analyses is not insignificant, as depression tends to afflict women at greater rates than men (Mazure and Jones, 2015, p. 6).

Women are also still particularly underrepresented in drug development trials. For example, women are still forbidden from participating in phase I trials and discouraged from participating in phase II trials. In addition, pregnant women are always excluded from drug trials, including almost any new drug, as they may be harmful to the fetus, and “women of childbearing age can participate only if they adhere to a strict birth control regimen” (Gochfeld, 2010, 192). Marketing campaigns for drug trials may also actively discourage women from participating in trials at the risk of possible reproductive consequences. While this may be in the best interest of pregnant women, it suggests that full equality in drug trials may never be achieved.

Areas of Research where Gender Disparities are Most Crucial
Women generally receive and seek out more healthcare than men. They visit the doctor more frequently, undergo more procedures, take more lab tests and medication, and spend more time in the hospital than men. Despite this, the majority of medical research is conducted on male subjects and the disparities in health typically affect women more harshly (Keville, 1994, p. 18). This is due to the fact that women are typically underrepresented in clinical trials. Long-term exclusion from clinical trials has had detrimental effects on the health of women around the world. Medical care and research differs for men and women, so this disparity in medical research results in gaps in knowledge and care in women’s health. Although women take more medication, most drugs are tested on men (Keville, 1994, p. 20). The NIH (National Institutes of Health) once funded a study of uterine and breast cancer and used male subjects. There are particular areas where research lacks female subjects, which can have detrimental effects on women’s health. A 2009 survey of research on non-human mammals showed a male bias in 8 out of 10 fields surveyed. These fields included neuroscience, physiology, pharmacology, endocrinology, zoology, behavioral physiology and behavior. Studies of males still prevail in biological literature, demonstrating how women are underrepresented in biomedical research (Beery and Zucker, 2011).

For many diseases, the symptoms manifest in different ways for females and males. The number one killer among men and women, heart disease, kills more women than men each year (Barlow, 2014). However many clinical trials do not address sex in symptom identification or treatment. (Westervelt, 2015). A study on the effects of aspirin on heart disease involved 22,071 subjects, all of which were male (Keville, 1994, p. 18). Another study on the the relationship between cholesterol levels and heart disease had 15,000 subjects, all men (Keville, 1994, p. 18). These discrepancies can be detrimental to women’s health, as epidemiological and clinical studies of men often have different results than those of women, exemplified by sex differences in response to many drugs in cardiovascular disease (Beery and Zucker, 2011).

Many issues that are prevalent in women’s health are a result of hormones. Depression, anxiety and Alzheimer's disease have all been shown to be more rampant in females due to hormones. Biologically there are different outcomes in the prevalence of diseases between the sexes. However, within the medical field, more work is done to evaluate disease without studying the effect gender plays in disease evolution.

Research on anxiety and depression have suffered from a lack of female representation in trials. For both anxiety and depression, there are a wide variety of medications someone may be prescribed by a healthcare provider. For each one of these, the medication prescriptions and efficacy depends on the body’s ability to metabolize them. However, less than 45% of clinical trials of antidepressants evaluate sex metabolism differences of the drug by running tests on female lab animals (Westervelt, 2015). The development of depression is different for every patient. The typical rationales behind a diagnosis are personal circumstances and experiences. However, genetics and other biological factors are often causes as well ( Mayo Clinic, 2016). Many clinical trials involving antidepressants and anti-anxiety medications do not include women. This is because it is believed that menstrual cycles, birth control, and overall hormone changes make it difficult to evaluate the efficacy of drugs. (Hillin, 2016) This gap in the prevalence of specific disease due to gender differences is not limited to depression and anxiety.

The prevalence of AIDS (Acquired Immune Deficiency Syndrome) is growing among women; HIV/AIDS is the leading cause of death among women of reproductive age (aged 15–44) (“Statistics: Women and HIV/AIDS”, 2017). In spite of this, most AIDS research still excludes women (Keville, 1994, p. 20). As of August 28, 1989, there were 7,659 patients enrolled in federally funded AIDS clinical trials organized by the National Institute of Allergy and Infectious Diseases (NIAID), of those 7,659 patients, 6.8% were female (Levine, 1990, p. 448).

Lung cancer also kills more women every year than breast, ovarian, and uterine cancers combined (Westervelt, 2015). Sex hormones make a difference in the way lung cancer progresses, thus researchers have found that some lung cancer treatments work better for women than men (Westervelt, 2015). That being said, more women are starting to participate in lung cancer trials, but they are less likely to enroll in trials then men (Westervelt, 2015).

Alzheimer's is another known disease that has a significantly higher prevalence in women. Similar to anxiety and depression described above, Alzheimer's also lacks the inclusion of women in clinical trials. Many people now label Alzheimer’s as a women’s disease because of its prevalence among women. Today, 16% of women will be diagnosed with Alzheimer's compared to 11% of men. It was only recently that Alzheimer's was believed to be biased by gender, and new research is looking to attribute this brain degradation to fluctuating levels of hormones during and after menopause. (Menopause, Female Hormones, 2017)

The exclusion of women in clinical trials has detrimental effects on both the understanding of a disease and its consequent treatment. Not including women in trials and research has created a substantial disparity in knowledge of health treatment between men and women. Additionally, by excluding women from medical research it creates an externality, as there are consequences to existing outside the discerning subject, that impact women’s health. If women were to be included in research it would create a positive global externality and everyone would benefit from

= Progress in the Medical Field = Although there has been progress in women’s health research in recent years, it is limited to a few areas and the discoveries are slow to be incorporated into practice. Women’s health has vastly benefited in the areas of research where ­a lot of progress has been made. For instance, since breast cancer research has advanced, mortality from breast cancer has declined (Institute of Medicine, 2010). This is mainly from the finding that hormone therapy can cause an increased risk of breast cancer – without researching women’s health, this discovery would have never been made and mortality from breast cancer would still be increasing. There has also been some progress in HIV treatment during the past 20 years; however, it is mostly due to research in men. Because of this male-focused research, many side effects from HIV treatment that occur in women, such as an increased risk of anemia and acute pancreatitis, were overlooked (Institute of Medicine, 2010).

National health organizations, such as the FDA and NIH, recognize the research gender disparity and have taken strides to reduce this gap. In 2015, the FDA discovered that many women were overdosing on Ambien – following this discovery they cut the dosage of Ambien for women in half. Since then, the FDA released a program to enforce taking sex differences into account regarding health guidelines (Westervelt, 2018). The NIH also adopted a policy of inclusion of women subjects. However, it was not mandatory, thus there was essentially no enforcement. For the reason, this policy was not effective for several years until it was recently strengthened (Keville, 1994).

Additionally, the conditions that have made a lot of progress are more common among women who are socially disadvantaged, meaning that some women are not benefitting from the progress being made because they can’t afford proper treatment (Institute of Medicine, 2010). Thus, even though more emphasis is being placed on researching women’s health, a gap still remains horizontally between women of different socioeconomic status’. In order to close this gap, researchers must also specifically study these groups of women to gain an adequate understanding of women’s health needs. If these groups are researched sufficiently this may help reverse the trend that people with lower income have a lower life expectancy.

The progress made in women’s health has been slow to be incorporated into practice. It can sometimes take 15-20 years and this could be due to many possible factors (Westervelt, 2010). For instance, in order for a study to be deemed comprehensive, it must be replicable and yield the same results time after time. Many studies, such as clinical trials and observational studies, also require a lot of time to complete. Because of the already large, existing research gap, it will take time to complete these trials in order to reduce this disparity. There may also be social and cultural opposition or financial obstacles that researchers face. Contributing to this, the NIH recently cut in half the donation it gives to train young health professions on how to include sex in research (Westervelt, 2010). With governmental, financial, social and cultural opposition to overcome before implementing knowledge into practice, the progress made in women’s health research, although occurring, is happening slowly.

= References = Depression in women: Understanding the gender gap. (2016, January 16). Retrieved March 28, 2018, from https://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression/art-20047725

Gender balance in research: new analytical report reveals uneven progress. (2018). Elsevier Connect. Retrieved 28 March 2018, from https://www.elsevier.com/connect/gender-balance-in-research-new-analytical-report-reveals-uneven-progress

Gochfeld, M. (2010). Sex-Gender Research Sensitivity and Healthcare Disparities. Journal of Women’s Health, 19. Retrieved March 27, 2018 from https://www-liebertpub-com.proxy.lib.umich.edu/doi/pdf/10.1089/jwh.2009.1632

Hillin, T. (2016, August 11). Women are often excluded from clinical trials because periods. Retrieved March 28, 2018, from https://splinternews.com/women-are-often-excluded-from-clinical-trials-because-p-1793861066

Institute of Medicine. 2010. Women’s Health Research: Progress, Pitfalls, and Promise. Washington, DC: The National Academies Press. Retrieved March 26https://doi.org/10.17226/12908

Jefferson, L., Bloor, K., & Maynard, A. (2015). Women in Medicine: Historical Perspectives and Recent Trends. 114(1).

Keville, T. (1994). Women's Rights Law Reporter. Women's Rights Law Reporter, 16. Retrieved March 27, 2018, from http://heinonline.org/HOL/Page?handle=hein.journals/worts16&page=18&collection=journals

Latest Alzheimer's Facts and Figures. (2018, March 19). Retrieved March 28, 2018, from https://www.alz.org/facts

Mazure, C. and Jones, D. (2015). Twenty Years and Still Counting: Including Women as Participants and Studying Sex and Gender in Biomedical Research. BMC Women’s Health, 15. Retrieved March 28, 2018 from https://search-proquest-com.proxy.lib.umich.edu/docview/1779951600?pq-origsit e=summon

Menopause, Female Hormones, and Alzheimer's Risk. (n.d.). Retrieved March 28, 2018, from https://www.awakeningfromalzheimers.com/menopause-female-hormones-and-alzheimers-risk/

Westervelt, A. (2015, April 30). The medical research gender gap: How excluding women from clinical trials is hurting our health. Retrieved from https://www.theguardian.com/lifeandstyle/2015/apr/30/fda-clinical-trials-gender-gap-epa-nih-institute-of-medicine-cardiovascular-disease