Dr. Blanca Coll-Vinent: “Applying the gender perspective means individualizing medicine in order to treat each patient better”

The gender perspective in the world of health is a subject that has been talked about for a long time: studies have been carried out for at least 30 years.  But this is the first time that there has been a specialized working group in the hospital.  In fact, the organizational meeting was held last December. The idea came from outside, from Vall d’Hebrón, which was implementing it and wanted to extend it to other centres, especially large hospitals in Catalonia. The aim is for more and more centres all over the country to join in and for the network to be under the umbrella of the Department of Health.  I spoke to the Medical Director, Dr. Castells, about this and he agreed, and we decided to choose a representative from each institute. There are also representatives from the hospital's different cross-cutting commissions, which may be relevant to this issue. 

It is still early days, not even six months have passed, and what we have done so far is to inform people:  to disseminate why it is important to apply the gender perspective for everyone’s benefit.  Because, when it comes to understanding a patient, it is very important to take sex- and gender-related differences into account. Both when making a diagnosis and when assessing the clinical manifestations, the patient’s history, the tests that are best suited to them, their prognosis and their follow-up. And that is part of a more global vision—individualized medicine—which is now very much in vogue. There is an increasing tendency to personalize medicine, in line with the specific characteristics of each patient, such as age, frailty, associated illnesses, the social situation, etc. And one of these characteristics, a very important one, is sex and gender.

By disseminating it: We carried out a survey of the entire hospital to generate interest in the subject, and so that our work was recognized, and we are trying to ensure it is one of the Hospital Clínic’s strategic lines of action. We are also preparing a joint session to present the Gender and Health Working Group to the different services and launch projects with them.  Finally, we also want to make an impact on the area of research, so that women are taken into account more when it comes to evaluating research projects.   

In the working group, we focus on healthcare, teaching and research. And one thing cannot be separated from the other. Because in healthcare, how can you know which drug is best to use if it has not been studied by researchers first? So, first of all, you have to carry out research. And how will you apply it if you don’t teach it to future doctors first? So, first you have to carry out research on the subject, disseminate the results and then apply them.  And then everything goes together. 

According to the studies carried out so far, women tend to go to the doctor less often and, above all, late: they don’t go to the doctor until they have lots of symptoms, and sometimes the disease is more advanced. On the other hand, there is the fact that the medicine that we all learned, above all those of us who are older, was largely based on uniform and androcentric models.  These are models based on studies in which many more men than women participated, or which excluded certain women, for example pregnant women. Therefore, we did not have enough information to know things about women’s characteristics. This means that we risk being mistaken in our assessment of their symptoms or their discomfort or their consultation.

These are pathologies that are under-studied, a process is normalized that perhaps should not be normalized: “it is normal for this to happen because she is menopausal, it is normal for that to happen because she is pregnant..." And it is not normal. A pathology is normalized simply because it is known to exist in women and it is little known. This happens far more with women than with men, and research has to be carried out to find out whether there are female illnesses that are underdiagnosed, and almost underestimated.  A lot of work has to be done on this. 

Sometimes, there are diseases that are not as rare in the other sex For example, ischaemic heart disease. It was always traditionally male—it is always a man who has a heart attack—and for many years it has been a very common disease in women.  In fact, cardiovascular disease is the leading cause of death for women.  Sometimes, the idea people have may be wrong because it is based on very old studies. 

The consequence of not including enough women in clinical trials is that we don’t have enough information. The reason for exclusion is somewhat practical: if you only include men, it's easier; women go through certain stages in their life that are very variable and that can alter the results. And that complicates things, but that is precisely why it is so important to include them. Because if you don't include them, you falsify the results; if you don’t include them, you don't have information. There are many drugs, such as psychotropic drugs, that affect men and women differently. There are also drugs that can lead to female infertility as a side effect, or can be teratogenic. (We cannot say to a woman: “don’t get pregnant when you are taking this drug”. We have to find an alternative. And there are lots of other similar things that are unknown.

Applying the gender perspective means individualizing medicine in order to treat each patient better. Because if we focus on their characteristics of age, gender, sex, weight, concomitant pathology, social situation, etc. we will treat them much better than if we only take into account an individual who is the same as the others.  Individualizing medicine by sex and by gender benefits everyone: men too. If the differences that might exist are analysed separately, even if their group is the predominant one, some new information is bound to be obtained. This may be the case of minority diseases in men, such as male breast cancer, male osteoporosis or lupus, for example.  What’s more, they are diseases that are associated with women because they are the ones who suffer from them most and no one thinks about men.

Here two things need to be taken into account: the biologically assigned sex you have and the gender, which is the sociocultural construct that is in theory associated with your sex. But this is not always the case. Medicine has to be adapted to each individual’s sex and gender. However, for the time being, in practice this is very hard to do. First of all, in the working group, we aim to separate men and women and, in the future, when this is well established and clear, we shall try to focus more on each person's gender and sex. In any case, that will be a second step that will definitely have to be taken.