In an extract from her new book, Dr Hazel Wallace lifts the lid on gender bias in medicine, and explains how women are still being treated with outdated guidelines based on male subjects
The Food Medic was born out of a passion project of mine back in 2012 while at medical school. After losing my father suddenly to a stroke in my teens, I became fascinated by how nutrition and lifestyle can influence our health and genetic predisposition to disease. However, in lectures, only lip service was paid to non-medical interventions like diet, physical activity, sleep and stress management, so I set out to learn more about how our lifestyle shapes our health and started to blog about my findings in accessible, easy-to-follow articles and social media captions as ‘The Food Medic’.
I wrote and published my first book, The Food Medic, in 2017, while working full-time as a first-year doctor in London, and released my second book, The Food Medic for Life, in 2018. Over this time, my passion for nutrition and public health continued to grow, which brought me back to university the following year to complete my master’s in clinical nutrition and public health at University College London (UCL), allowing me to become dual-registered as a doctor and a nutritionist.
Nutrition will always be my biggest passion, but as a woman, and as a doctor to many women, I wanted to expand the work I do, especially when I discovered there was an unmet need within medicine and healthcare. I realised that our current model of male-centric medicine meant that women were understudied, underdiagnosed, misdiagnosed and undertreated. In most of the research I studied, it appeared that medicine sees our reproductive organs and hormones as our greatest source of difference to men and holds the assumption that pretty much everything else works in the same way, so can be fixed in the same way. But, in the words of Dr Stacy Sims, “women are not small men”.
The more I shared female-focused research (albeit limited) and content online, the more women responded. My direct messages on Instagram would be filled with women who had similar experiences and felt like they weren’t being listened to. Every post I curated that examined health topics under a female lens turned into an engaged and empowered discussion among my followers — among many of you. It made me want to learn more, to share more, to empower more. I knew there was an unmet need here and wanted to find some answers.
And so, for the past three years (in between Covid shifts at the hospital), I’ve dedicated most of my time to researching how to help women live healthier, happier lives. And The Female Factor was born.
How science sees women
The male body has always been the default body in biomedical research, and female subjects have been historically excluded. Here’s the thing, we have so much incredible medical research available to us now, but most of it is based on male cells, male mice and male bodies, then simply applied to women.
I’ll say that again for the people in the back: most clinical research ignores the female sex and is centred around cis (a person whose sense of personal identity and gender corresponds with their birth sex.), endosex (a person born with sex characteristics that are considered typically male or female) men. It is also worth highlighting that transgender women are similarly excluded from medical research, even if their healthcare needs are not the focus of this particular book.
Even when it comes to research based on animals, there is a significant male bias in eight out of 10 areas of biology. For example, in studies of drug treatments, there is a five-to-one male-to-female ratio. That’s quite concerning considering women typically respond to drug treatments differently and experience adverse drug reactions nearly twice as often as men.
An analysis of prescription drugs withdrawn in the US market from 1997 to 2001 found that eight out of 10 posed ‘greater health risks for women’. This is not simply because women are ‘smaller men’ (though, on average, we are smaller humans), but we also have smaller organs, more body fat (which can trap certain drugs), slower gut motility (affects drug absorption) and excrete drugs slower via the kidneys — all of which increase the risk of overmedication and adverse reactions, if not accounted for.
Historically, researchers have argued that the female body is too complex to be included in studies due to fluctuating hormones and the risk of pregnancy, or that women are too difficult to recruit because of their caregiving responsibilities and the inflexibility of research trials. The latter being an argument that is simply infuriating and underpins the complex relationship between our sex (biology) and gender stereotypes (and the social norms that come with it), and how they both influence our health and the healthcare we receive.
Research into unique reproductive or gynaecological health problems that affect women and people assigned female biologically at birth isn’t any better. For example, only 2.5pc of publicly funded research is dedicated to reproductive health, despite the fact that nearly one in three women will suffer from a reproductive or gynaecological health problem in their life.
Indeed, inequalities in health and research for women is also compounded by race and class. While it takes, on average, an already unacceptable eight years for a woman to be diagnosed with endometriosis, in the UK, black women are shockingly half as likely as white women to be diagnosed.
Our deeply embedded beliefs and unconscious biases that we hold about women and their health experiences are causing unnecessary — and preventable — suffering.
From research to healthcare, as well as the media narrative, it is all biased toward men, and the aim of this book is to dismantle and change that narrative.
Here’s the thing: our fluctuating hormones may be considered a ‘nuisance’ for researchers, but actually they provide us with additional insight into the inner workings of our bodies. Sex hormones are not only orchestrating our reproductive health, but affecting our metabolism, as well as our bone, heart, gut and brain health... and even the way we sleep.
Similarly, across the lifespan, women experience important hormonal milestones — puberty, perinatally and after the menopause — which alter how our bodies function and can be windows of vulnerability for certain health conditions such as depression, anxiety and insomnia.
Although healthcare professionals strive for equal treatment of all patients, sex and gender bias exists throughout the healthcare system, from the interactions between patients and doctors to the medical research and policies that govern it. Indeed, this bias does not only affect one gender, but it disproportionately affects women and can have a serious impact on their health and healthcare. For example, women are diagnosed later for heart disease, not only because it is still largely considered a ‘man’s disease’, but also because our understanding and diagnostic tests are male-biased. I wasn’t aware of this at medical school — I hope that future medics will be.
Fortunately, in recent years, there has been a big drive to improve the sex/gender gap in research, but there is still a long way to go, and women are still being medically treated with outdated guidelines based on male subjects and a male-centric narrative.
Changing the narrative
While you may not sit around reading research papers for fun (just me, right?), this gendered information is reaching you through the media, whether that be published or social. News headlines read ‘Heart Attacks Kill Men’, when, in fact, they’re the biggest killer of both sexes. Meanwhile, social media posts tell women to #Tone, #Sculpt and #Fast, instead of #Build, #Bulk and #Fuel.
Even from an early age, we are being sold the message that females are inferior — ask young children to draw a scientist and they are more than twice as likely to draw a man than a woman.
Unsurprisingly, children’s science books contain pictures of males three times more often than females, reinforcing the stereotype that science is a man’s pursuit and also influencing girls’ perceptions of what they are (or aren’t) capable of.
You might think that picture books aren’t important, but they mimic what the advertising industry is doing every time we open a magazine, scroll through a social media app or watch TV. It’s this glass ceiling that prevents women from achieving their full potential — but you are not weaker, you are not less smart, you are not less capable... and science backs this up!
My intention with this book is to empower women, not shout about all the ways in which we have been hard done by. This is also not a ‘f**k you’ to men — I love men, but I dislike the repression and underrepresentation of women.
So, with this book, I am expanding the definition of ‘women’s health’ from conditions that only affect our reproductive organs, to the study of all aspects of health and disease, with the recognition that presentation, diagnosis, treatment and prevention may be different between the sexes.
There are some things we can’t change — like our genes — but by understanding our unique female physiology, we can harness this information to improve our health and reduce our risk of illness. This book provides you with a method to do just that, helping you to make your body work with you, not against you.
The Female Factor: Making women’s health count — and what it means for you by Dr Hazel Wallace is published in hardback by Yellow Kite, €23.99, from Eason