Translator: Joseph Geni Reviewer: Ivana Korom
We all go to doctors.
And we do so with trust and blind faith
that the test they are ordering and the medications they're prescribing
are based upon evidence --
evidence that's designed to help us.
However, the reality is that that hasn't always been the case for everyone.
What if I told you
that the medical science discovered over the past century
has been based on only half the population?
I'm an emergency medicine doctor.
I was trained to be prepared in a medical emergency.
It's about saving lives. How cool is that?
OK, there's a lot of runny noses and stubbed toes,
but no matter who walks through the door to the ER,
we order the same tests,
we prescribe the same medication,
without ever thinking about the sex or gender of our patients.
Why would we?
We were never taught that there were any differences between men and women.
A recent Government Accountability study revealed that 80 percent of the drugs
withdrawn from the market
are due to side effects on women.
So let's think about that for a minute.
Why are we discovering side effects on women
only after a drug has been released to the market?
Do you know that it takes years for a drug to go from an idea
to being tested on cells in a laboratory,
to animal studies,
to then clinical trials on humans,
finally to go through a regulatory approval process,
to be available for your doctor to prescribe to you?
Not to mention the millions and billions of dollars of funding
it takes to go through that process.
So why are we discovering unacceptable side effects
on half the population after that has gone through?
What's happening?
Well, it turns out that those cells used in that laboratory,
they're male cells,
and the animals used in the animal studies were male animals,
and the clinical trials have been performed almost exclusively on men.
How is it that the male model became our framework for medical research?
Let's look at an example that has been popularized in the media,
and it has to do with the sleep aid Ambien.
Ambien was released on the market over 20 years ago,
and since then, hundreds of millions of prescriptions have been written,
primarily to women, because women suffer more sleep disorders than men.
But just this past year,
the Food and Drug Administration recommended cutting the dose in half
for women only,
because they just realized that women metabolize the drug
at a slower rate than men,
causing them to wake up in the morning
with more of the active drug in their system.
And then they're drowsy and they're getting behind the wheel of the car,
and they're at risk for motor vehicle accidents.
And I can't help but think, as an emergency physician,
how many of my patients that I've cared for over the years
were involved in a motor vehicle accident
that possibly could have been prevented
if this type of analysis was performed and acted upon 20 years ago
when this drug was first released.
How many other things need to be analyzed by gender?
What else are we missing?
World War II changed a lot of things,
and one of them was this need to protect people
from becoming victims of medical research without informed consent.
So some much-needed guidelines or rules were set into place,
and part of that was this desire to protect women of childbearing age
from entering into any medical research studies.
There was fear: what if something happened to the fetus during the study?
Who would be responsible?
And so the scientists at this time actually thought
this was a blessing in disguise,
because let's face it --
men's bodies are pretty homogeneous.
They don't have the constantly fluctuating levels of hormones
that could disrupt clean data they could get if they had only men.
It was easier. It was cheaper.
Not to mention, at this time, there was a general assumption
that men and women were alike in every way,
apart from their reproductive organs and sex hormones.
So it was decided:
medical research was performed on men,
and the results were later applied to women.
What did this do to the notion of women's health?
Women's health became synonymous with reproduction:
breasts, ovaries, uterus, pregnancy.
It's this term we now refer to as "bikini medicine."
And this stayed this way until about the 1980s,
when this concept was challenged by the medical community
and by the public health policymakers when they realized that
by excluding women from all medical research studies
we actually did them a disservice,
in that apart from reproductive issues,
virtually nothing was known about the unique needs
of the female patient.
Since that time, an overwhelming amount of evidence has come to light
that shows us just how different men and women are in every way.
You know, we have this saying in medicine:
children are not just little adults.
And we say that to remind ourselves
that children actually have a different physiology than normal adults.
And it's because of this that the medical specialty of pediatrics came to light.
And we now conduct research on children in order to improve their lives.
And I know the same thing can be said about women.
Women are not just men with boobs and tubes.
But they have their own anatomy and physiology
that deserves to be studied with the same intensity.
Let's take the cardiovascular system, for example.
This area in medicine has done the most to try to figure out
why it seems men and women have completely different heart attacks.
Heart disease is the number one killer for both men and women,
but more women die within the first year of having a heart attack than men.
Men will complain of crushing chest pain --
an elephant is sitting on their chest.
And we call this typical.
Women have chest pain, too.
But more women than men will complain of "just not feeling right,"
"can't seem to get enough air in,"
"just so tired lately."
And for some reason we call this atypical,
even though, as I mentioned, women do make up half the population.
And so what is some of the evidence to help explain some of these differences?
If we look at the anatomy,
the blood vessels that surround the heart are smaller in women compared to men,
and the way that those blood vessels develop disease is different
in women compared to men.
And the test that we use to determine if someone is at risk for a heart attack,
well, they were initially designed and tested and perfected in men,
and so aren't as good at determining that in women.
And then if we think about the medications --
common medications that we use, like aspirin.
We give aspirin to healthy men to help prevent them from having a heart attack,
but do you know that if you give aspirin to a healthy woman,
it's actually harmful?
What this is doing is merely telling us
that we are scratching the surface.
Emergency medicine is a fast-paced business.
In how many life-saving areas of medicine,
like cancer and stroke,
are there important differences between men and women that we could be utilizing?
Or even, why is it that some people get those runny noses
more than others,
or why the pain medication that we give to those stubbed toes
work in some and not in others?
The Institute of Medicine has said every cell has a sex.
What does this mean?
Sex is DNA.
Gender is how someone presents themselves in society.
And these two may not always match up,
as we can see with our transgendered population.
But it's important to realize that from the moment of conception,
every cell in our bodies --
skin, hair, heart and lungs --
contains our own unique DNA,
and that DNA contains the chromosomes that determine
whether we become male or female, man or woman.
It used to be thought
that those sex-determining chromosomes pictured here --
XY if you're male, XX if you're female --
merely determined whether you would be born with ovaries or testes,
and it was the sex hormones that those organs produced
that were responsible for the differences we see in the opposite sex.
But we now know that that theory was wrong --
or it's at least a little incomplete.
And thankfully, scientists like Dr. Page from the Whitehead Institute,
who works on the Y chromosome,
and Doctor Yang from UCLA,
they have found evidence that tells us that those sex-determining chromosomes
that are in every cell in our bodies
continue to remain active for our entire lives
and could be what's responsible for the differences we see
in the dosing of drugs,
or why there are differences between men and women
in the susceptibility and severity of diseases.
This new knowledge is the game-changer,
and it's up to those scientists that continue to find that evidence,
but it's up to the clinicians to start translating this data
at the bedside, today.
Right now.
And to help do this, I'm a co-founder of a national organization
called Sex and Gender Women's Health Collaborative,
and we collect all of this data so that it's available for teaching
and for patient care.
And we're working to bring together the medical educators to the table.
That's a big job.
It's changing the way medical training has been done since its inception.
But I believe in them.
I know they're going to see the value of incorporating the gender lens
into the current curriculum.
It's about training the future health care providers correctly.
And regionally,
I'm a co-creator of a division within the Department of Emergency Medicine
here at Brown University,
called Sex and Gender in Emergency Medicine,
and we conduct the research to determine the differences between men and women
in emergent conditions,
like heart disease and stroke and sepsis and substance abuse,
but we also believe that education is paramount.
We've created a 360-degree model of education.
We have programs for the doctors, for the nurses, for the students
and for the patients.
Because this cannot just be left up to the health care leaders.
We all have a role in making a difference.
But I must warn you: this is not easy.
In fact, it's hard.
It's essentially changing the way we think about medicine
and health and research.
It's changing our relationship to the health care system.
But there's no going back.
We now know just enough
to know that we weren't doing it right.
Martin Luther King, Jr. has said,
"Change does not roll in on the wheels of inevitability,
but comes through continuous struggle."
And the first step towards change is awareness.
This is not just about improving medical care for women.
This is about personalized, individualized health care for everyone.
This awareness has the power to transform medical care for men and women.
And from now on, I want you to ask your doctors
whether the treatments you are receiving are specific to your sex and gender.
They may not know the answer --
yet.
But the conversation has begun, and together we can all learn.
Remember, for me and my colleagues in this field,
your sex and gender matter.
Thank you.
(Applause)