GENDER HEALTH GAP:
how our medical system is cheating women
The sun was shining when Rebecca Keyes arrived at Redlands Hospital, Queensland. She had planned to go straight to work after her appointment and her high heels clicked on the tiles of the bustling foyer as she made her way to the ultrasound desk.
Rebecca was suffering an in amed gall bladder. The scan would reveal the extent of the problem. Rebecca told the technician she was also experiencing some pain and swelling in her left breast, and the technician offered to have a look.
Rebecca had been pregnant with her third child when the lump appeared. One evening, putting her toddler to bed, she had tripped over and landed on her breast. Initially her GP diagnosed a haematoma – a result of the fall. The lump persisted though – growing into a tennis ball-sized mass – but Rebecca’s GP was unmoved. “He said it was just taking time to heal,” she told The Weekly when we spoke with her last August.
At another appointment, the GP told Rebecca that the changes she was observing in her breast were results of pregnancy and childbirth. He waved away her concerns. “He made me feel like I was being really silly – like I was wasting his time,” Rebecca said.
Back at Redlands Hospital, the technician had called for a doctor. She’d found uid under Rebecca’ lungs and wanted to investigate further with a CT scan. As far as Rebecca was concerned there was nothing to worry about, but when the technician asked if she had anyone with her, alarm bells started to ring.
“I called my sister and she came in [with her son] and sat with me. When the doctor came in with the results, he asked my nephew to step outside. My sister and I looked at each other like, ‘what’s going on?’” Rebecca recalled.
“He said: ‘We’re so sorry to tell you this, but you have stage four breast cancer. It’s in your left breast, your lymph nodes, there are two spots on your spine and a spot in your liver.’” Last October, Rebecca suffered a seizure and was rushed to hospital. The cancer had spread to her brain and was growing aggressively. She passed away three weeks later. Rebecca was 36 years old.
When we spoke with her, Rebecca was mindful not to torment herself with too many what ifs, but she knew that the outcome might have been different if her cancer had been discovered six months earlier, when she rst saw her GP. She was told that she was too young to have breast cancer. She has paid for that assumption with her life.
Alarmingly, the attitude of Rebecca’s GP is not uncommon. A 2018 report from the Breast Cancer Network Australia found that women under 40 who are reporting their breast cancer symptoms to their doctors are not being taken seriously. It’s not the rst report to have noted GPs dismissing female patients. A study from the UK in 2015 revealed a longer time lag from the onset of symptoms to diagnosis in female patients in six out of 11 types of cancer. Likewise, a UK study investigating bladder cancer found that women often had to make more than three visits to their doctor before getting a referral to a specialist, while men were more likely to receive an immediate referral.
Studies on conditions as varied as brain tumours, Crohn’s disease and dementia also show gender disparity.
There is one thing that all these studies have in common – women are routinely being short-changed by their healthcare providers. Julia Buckly, a journalist and author of Heal Me – In Search Of A Cure (2017, Weidenfeld & Nicolson), says gender bias in health care has reached epidemic proportions globally. “Study after study backs this up. Women are twice as likely to have their pain ascribed to psychological reasons, and half as likely to be adequately medicated as men,” she tells The Weekly.
“I think we’re conditioned to think of women as more emotional, and this colours how [medical professionals] view us as patients. They’re human, after all.”
Julia has experienced gender bias rsthand. It took doctors four years to diagnose her with Ehlers-Danlos syndrome (a genetic condition that affects connective tissue), a process that took its toll emotionally. Looking back now, Julia believes that she was ‘gaslighted’ by doctors who repeatedly told her that her symptoms were all in her head.
“I believed it because the doctors said so. And because it didn’t tally with how I was actually feeling, it made me doubt myself. Nothing seemed to make sense. I thought I was genuinely going mad,” she recalls.
Dr Coralie Wales, a pain counsellor and the president of Chronic Pain Australia, says it’s common for women to start doubting themselves when they’re told their pain is psychological. “You start to lose part of your identity because you’re no longer certain about who you are.
It’s really detrimental,” she explains. Women who have been reporting pain for a long time can pay a hefty price psychologically. “If you can’t nd an answer and nobody believes you then you become despondent, distrustful and eventually you give up hope,” she says.
It’s so common for doctors to stereotype women’s pain that even the medical media are doing it. A recent practice question from Medescape, a global news and education site, asked doctors to assess a ctitious female patient who reports unexplained pain. The correct answer was “Munchausen syndrome”, a “factitious” condition in which a patient invents symptoms. In other words, the creators of the Medescape quiz believe that a woman with undiagnosed pain must be either imagining it or making it up.
Being told that it’s all in your head is an experience common to sufferers of endometriosis, a disease in which tissue similar to the lining of the womb grows in other parts of the body. Symptoms include debilitating pain, in ammation, nausea and reduced fertility.
In July, the Health Minister, Greg Hunt, announced a new National Action Plan for Endometriosis, along with funding for new research. He also issued an apology.
“This condition should have been acknowledged at an earlier time in a more powerful way, and it will never be forgotten again,” he said.
The director and co-founder of Endometriosis Australia, Donna Ciccia, says the apology means a lot to women who have fought for their debilitating symptoms to be recognised. “Women are now feeling that the disease is starting to be taken seriously,” she says. “It can be soul crushing when no one believes you or understands that what is happening to you is through no fault of your own.”
We’ve nally reached a point where endometriosis, which affects more than 10 per cent of Australian women, is receiving the gravitas that it warrants. But why has it taken so long? For Donna the answer is simple – taboo. “There is much stigma associated with menstruation which has been a major part of the problem,” she explains.
With the national action plan in place, the future is looking brighter. However, Donna notes that the role gender bias has played in the suffering of endometriosis patients remains a sore point. “Many women have been told to ‘harden up’, ‘just take paracetamol’, that ‘it’s all in your head’ or ‘you must just have a very low pain threshold’,” she says. And for some women, the national action plan comes way too late.
Kathryn Hamilton, now 47, endured 10 years of crippling pain before being diagnosed with endometriosis. During her illness, Kathryn was regularly dismissed by her family GP. “He just kept saying, ‘It’s normal, it’s ne’.” It wasn’t ne though. When she eventually sought a second opinion, she was immediately referred for an ultrasound and Kathryn found she was riddled with endometriosis from her pelvis to her rib cage. “It was the size of a attened watermelon. Flat and huge,” she tells The Weekly.
The hysterectomy Kathryn needed came as a huge blow. “It took weeks to heal physically but emotionally I was quite depressed. I just felt devastated. I felt violated,” she recalls.
Kathryn has lingering feelings of resentment about the family GP who didn’t take her pain more seriously. “All
Women who suffer a serious heart attack are half as likely to receive proper treatment in an Australian hospital as men and have a greater risk of experiencing problems with their care. Recent research from the University of Sydney
those years, he never sent me to [a specialist], he just let it slide. The thing that I feel most angry about is that he left me in pain.”
Why didn’t she seek a second opinion sooner? It’s a question that gets levelled at Kathryn a lot. It’s a question she asks herself, too. “I trusted him,” she says. “You grow up with the belief that you have a family doctor, and you always see the same one.”
Of course, there are many conditions, including endometriosis and gynaecological cancers, that are biologically exclusive to women. But there are also signi cant gender differences in outcomes for diseases that impact men and women. Recent research from the University of Sydney found that, while heart disease is the leading cause of death in both men and women, there are stark differences in care. The study found that women who suffer a serious heart attack are half as likely to receive proper treatment in an Australian hospital as men and have a greater risk of experiencing problems with their care.
Dr Clara Chow, Professor of Medicine and Academic Director at Westmead Applied Research Centre, led the study. “I think we need to be conscious of potential gender differences and think about it when we assess and manage our patients,” she tells The Weekly.
Another issue is awareness. Surveys indicate that many women don’t see heart disease as a threat. “We [health professionals] need to be constantly talking about heart disease affecting both men and women,” she says.
In August, a US study into heart attack patients revealed another startling inequality in health care. Women have a better chance of surviving a heart attack if they’re treated by a female doctor. Researchers examined 580,000 patient records from Florida emergency departments to look for trends in age, gender and risk factors. Analysis showed that men and women had similar chances of survival if they saw female doctors. Male doctors were linked to poorer outcomes, especially for women.
Dr Brad Greenwood, associate professor at the University of Minnesota, led the study. He speculates that the trend might be due to the comfort factor. “One [reason for the trend] could be that female patients are more comfortable advocating for themselves with a female physician,” he told The Guardian. “[Or] it could be because women are more likely to present atypically and female physicians are better at picking up cues than their male colleagues.”
If women face an unconscious bias, then women of colour face a double bias. A 2016 study from the University of Virginia found healthcare providers underestimate African-American patients’ pain. Likewise, research published in 2012 in the journal Medical Care found African-American and Hispanic patients who reported severe pain in emergency were 22 per cent less likely to receive pain medication than white patients who presented with the same complaints. Meanwhile, new data from New York shows African-American women are 12 times more likely to die from pregnancy or childbirth-related causes than their white counterparts.
In Australia there is a welldocumented health gap between Indigenous and nonIndigenous people, and Aboriginal women are disproportionately affected by gender bias. Aunty Kerrie Doyle, Associate Professor of Indigenous Health at RMIT University, tells The Weekly there is a de nite healthcare bias against Aboriginal women.
“A poignant piece of research demonstrated that, after abdominal surgery, Aboriginal women were given less pain relief than non-Aboriginal women,” she says. “The reasons why this occurred included racist-based issues such as
‘oh, they don’t feel pain in the same way’ or ‘she never complained’. Of course all humans feel pain. This research demonstrates the cultural haughtiness and white privilege of some healthcare professionals.”
Doyle notes that issues such as cultural shyness and fear of shaming mean that Aboriginal women often won’t ask for help if trust hasn’t already been established.
“Healthcare providers need to be skilled in cultural pro ciency, not just cultural safety,” she insists. “Get to know your local communities, be engaged with Indigenous healthcare professionals, develop cultural humility and consider the message is more important than the messenger.”
In the UK, the issue of gender inequity in healthcare has been addressed in a new report from the British Medical Association. The report says that the system must do more to address women’s needs. One proposal is that the health service should provide gender-speci c services. There are no similar plans in Australia. In an email, the Royal Australian College of General Practitioners CEO Dr Zena Burgess told The Weekly that the college is not aware of any evidence that supports gender bias in Australian general practice. She notes that, if patients don’t think their symptoms have been taken seriously, they should “raise their concerns with their GP or speak to another GP”.
Rebecca Keyes spent her last few months taking life one day at a time. “It’s hard, especially with the kids. Not knowing how much longer I’m going to have with them, and trying to make memories for them,” she said. “I just try to live as best as I can and make life happy for them. I show them that I might be sick, but ... I’m ghting as hard as I can.” Her family stresses that the message Rebecca wanted to pass on to all women was, “check your boobs”.
To the health practitioners who dismiss women’s symptoms, Rebecca had this to say: “We know our bodies, if we think there’s something wrong, there is probably something wrong. Just listen and take us seriously.”