November 11, 2020 1:01 PM
In the early 1990s Bernardine Healy, cardiologist, director of the National Institute of Health in the United States, realized that more errors were made in diagnosing a heart attack if the patient was a woman, which also led to incorrect or incorrect treatment. resolutive. He wrote to us an article in the New England Journal of Medicine and entitled it “Yentl Syndrome”, borrowing the name of the protagonist of a short story by Isaac B. Singer.
In the story, Yentl was the daughter of a rabbi, forced to disguise herself as a man in order to gain access to the study of the Talmud, the sacred text of Judaism. With this reference, Dr. Healy wanted to show how women were discriminated against in medicine too.
Traditionally, studies of the diseases that affect men and women – and the drugs to treat them – have been conducted almost exclusively on men and then applied to women. In a few cases the opposite has happened, while clinical studies conducted according to gender are almost totally absent. The consequences of this absence affect the right to health and the right to treatment.
As Dr. Healy noted, for example, heart attack has always been considered a male pathology and based on this belief, diagnosis and treatment have been studied. Despite representing the leading cause of death for women, it is often not diagnosed because it can have different symptoms than those that occur in men: not pains in the chest and arm, but anxiety, dyspnea, stomach pain. Symptoms defined as “atypical”. The patients themselves neglect these signals, and sometimes doctors in hospitals send them in green code or arrange for them to be admitted to internal medicine, wasting precious time to save their life.
A new vision
Heart attack is the most common case, but it is not the only one. For this reason, a medicine that takes this into account, called gender-specific medicine (gender-specific medicine).
“It is not a new field of medicine, it is a transversal vision that tries to understand with which symptoms a disease manifests itself in a woman and with which in a man, and how to set up prevention and treatment”, explains Dr. Giovannella Baggio, president of National study center on health and gender medicine. “It has been realized that symptoms, treatments, prevention and drug effects are very different between men and women”.
There are cases of the opposite sign such as osteoporosis or depression, associated more with women and studied on them, although they also affect men. But they are still the minority, female bodies are the big ones excluded from disease research and drug testing.
Until 1993, women were excluded from drug testing studies
The reasons are different. “The woman has always been considered a being inferior to man from the biological point of view. Galen in the second century after Christ said that the woman was characterized by poorly developed, introverted genital organs. Vesalius, considered the father of anatomy, in 1500 argued that it was enough to study the male body and then apply everything else to the female one “, says Silvia De Francia, researcher in pharmacology at the University of Turin and author of the book The medicine of differences. Stories of women, men and discrimination.
Another issue concerns the greater complexity of female organisms as objects of study. From the first menstruation onwards, women have a highly variable hormonal system. These changes also affect the response or absorption level of the drugs. And therefore it is more complicated and expensive to foresee a high female involvement.
“Until 1993, women and rats were excluded from drug testing studies. It means that some of them, very common today, have only been tested on men ”, underlines De Francia. An example is that of aspirin: “It is a drug used in both anti-inflammatory and cardiovascular therapies to prevent heart attacks or strokes. Conducted at the turn of the 1980s, the test involved around twenty thousand people around the world. Only men”.
Today things have improved slightly, but the percentages still show an unbalanced situation. “In the initial phases of a study on a drug, those on its safety, women do not exceed 20-25 percent of the people involved”, explains Dr. Alessandra Carè, head of the reference center for gender medicine of the Institute superior health care (Iss).
Carè explains what usually happens, even in the oncology field: “You take a drug studied on men (people who they weigh an average of 70 kilograms, ed), and the doses are reshaped according to the weight of women, even if the metabolisms are different ”, underlines Carè.
The national plan
In 2018 in Italy it was approved a law which for the first time in Europe requires that gender be taken into account in medicine, in the clinical trials of drugs, in diagnostic-therapeutic pathways, in research, in the training of all health professionals and in communications with citizens. In 2019 the implementing decree was signed and a national plan on gender medicine.
According to Dr. Carè, the approval of the text was “a huge step forward”, because the plan “defines the objectives, the actors and the actions to be taken”. The legislation provides that every year the Minister of Health reports to parliament on the evolution of the situation in Italy and that an observatory on gender medicine is created.
Pending its establishment, at the end of January 2020 the regional representatives for the application of the national plan met. “A somewhat informal meeting, where everyone brought their own experiences”, explains Carè. “There is still a lot of work to be done because the situation at the national level is very heterogeneous. There are regions that have already organized gender clinical paths and structures with a correct gender vision, such as Tuscany, and others that have yet to start work in this sense. But we hope to be able to take this aspect forward, even if in small steps “.
Also for Dr. Baggio it is a good time for Italy, “but there is a need for universities to work well, for the regions to take matters into their own hands and oblige local health authorities to train on this topic. And then it’s up to the agencies that deal with establishing the rules of the sector. The Italian Medicines Agency no longer accepts research protocols if there is not the right attention to gender; same thing the European agency. A little at a time it is hoped that everything will find its way and a scientific and human correctness ”.
The fight against covid-19
The steps taken in the direction of gender-specific medicine are more relevant than ever in this moment of study, experimentation and treatment on the new coronavirus.
“The woman with covid-19 dies much less than the man, the ratio is almost 1 to 3 up to the age of eighty. For the moment it is statistics, but it is a fact that must be studied ”, explains Baggio. “There are many hypotheses and they are interesting, for example we have to take into account the immune system of women, which is stronger than that of men. It is important to work with a gender perspective on everything we are doing on covid-19, including vaccines ”.
The data collected at the end of February in China they reported a higher lethality rate of the new coronavirus for males (4.7 percent) than for women (2.8 percent). Differences similar were found Also in Italy from the Iss. According to the institute, the fatality rate for men (17.1 percent) is about double that of women (9.3 percent).
Much has also been said about this aspect in the media, giving new visibility to a gender approach to medicine. According to Carè “citizens have started asking questions. The health crisis has shown the need for proper disclosure and above all to investigate these differences, to then exploit them from a therapeutic point of view “.