Introduction

The women’s health movement, which emerged during the 1960s and 1970s along with the second wave of feminism, recognized the female body as the vessel that mediates male dominance. Feminists demanded improved healthcare and the elimination of sexism in healthcare systems. Activists fought to empower women’s knowledge, gain control over reproductive rights, and reclaim power from the paternalistic medical community [1]. They likewise battled against the oppression of women, manifest in the denial of access to abortions and contraceptives, prostitution, sexual violence, pornography, and beauty industry standards. Later, feminists criticized the medicalization and commercialization of reproduction and labor and the exploitation of underprivileged women in the reproductive industry [2].

Feminist thinkers coined the term “gender” to differentiate between biological and social aspects of being male or female and to emphasize the role of culture and society in the construction of human sexuality [3]. Later thought problematized the biological category of sex itself, pointing to it as a social construct no less than gender [4]. Moreover, recent scientific evidence reveals that it is impossible to separate sex and gender [5, 6], and that the dichotomy of two sexes is ignoring a more complex biological and social reality [7].

The new discipline of gender medicine (GM) aspires to examine the influence of gender on general medical issues. It argues that modern medical knowledge is based on observations and trials conducted mainly on men and that this wrong should be righted to achieve medical knowledge better suited to women [8]. The International Society for Gender Medicine (IGM) was founded in 2006 and was embraced by the European Union and the FDA [9]. It is consulted by institutions such as the Israeli parliament [10] and professional societies, for example the European Federation of Internal Medicine [11]. The IGM was granted financial resources from the European Union to promote its cause [12] and holds international conferences. Recently, medical schools introduced GM into their curricula. Since many consider the IGM to be representative of women’s health interests, it is vital to assess its views and actions and their implications for women [13]. Moreover, the recognition of GM as a discipline and its endorsement by the professional milieu is an opportunity to assess the attitude of the bio-medical world to feminist thinking and criticism. Thus, our goal was to analyze GM from a feminist perspective.

Methods

For this purpose, we reviewed scientific publications by past and present officials of IGM and of the Israeli Society for Gender and Sex Conscious Medicine (ISGSCM), listed on their websites, as well as their public appearances and press interviews. The scientific literature review included 27 articles concerning sex/gender-related issues published from 2010 until May 2020 in journals with an impact factor of 4 or more or a rank of 40 or less. In addition, we reviewed the report of the European Gender Medicine Network (EUGENMED) [12], an extensive project held between 2013 and 2015, that aimed to summarize the scientific data on gender and medicine and formulate recommendation for future policies. The popular media literature review included 24 relevant interviews and articles that were retrieved by searching the internet for entries containing the names of the IGM and the ISGSCM officials and reviewing their content. Interviews and articles in English and Hebrew, containing discussions on sex/gender and medicine, were included. Popular media publications were included in the analysis because GM has an explicit political agenda which it aims to promote also in popular venues.

Our study builds on the Foucauldian analysis of knowledge looking into the relationship between discourse and power, through the lens of the discourse of professional disciplines, in order to study the boundaries of thought used in a given time and discipline [14]. Thus, we analyzed the studied texts through the lens of power/knowledge relationships, ideology, and inequality. We formed two integrated files, one consisting of medical publications, the second of texts from the media. The texts were analyzed using a qualitative analysis method. Main themes concerning sex/gender and medicine were extracted from the texts inductively [15]. In addition, in dialog with themes in the feminist literature, we searched for what is missing in the discussion, in a deductive manner. The first two authors of the study who are MD’s read and discussed in several rounds the first medical file, identifying themes, and matching them with the relevant literature. The second file was analyzed by the third author, who is a social scientist. As a second step agreements were reached between all authors to prevent the potential bias of a single researcher and using inter-rater reliability to increase the validity of the results.

We hereby critically assess these publications in the context of current feminist thinking, noting both the topics discussed and those that were overlooked, or only seldom mentioned. After presenting our findings we discuss their implications.

Analysis of GM works

The scientific articles we reviewed focus on several subjects: Seventeen articles focused on the association between sex/gender, risk of disease and response to therapy, mainly in the field of cardiovascular diseases and related disorders [16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. Two articles studied the influence of sex/gender on treatment decisions and care plans [33, 34]; 5 articles focused on associations between sex/gender and the human brain, cognition, and mood [25, 35,36,37,38] ; 2 dealt with the effect of sex/gender on working conditions and promotion in healthcare [39, 40], 2 focused on sex/gender in medical education [41, 42] and 1 focused on sex in preclinical research [43]. The articles we reviewed are summarized in Table 1. The EUGENMED project summary reported on 5 working fields: 1. Sex/gender, risk of disease and treatment outcomes in cardiovascular medicine, pulmonary medicine, diabetes mellitus and psychiatry (depression). 2. Sex/gender and public health, focusing on risk factors for non-communicable diseases 3. Sex/gender in basic research. 4. Sex/gender in medical education. 5. Sex/gender and pharmacology, clinical trials and pharmaceutical regulation [12]. Each summary of a working field contained a detailed review of scientific literature and advocacy for future actions.

Table 1 Summary of the GM scientific publications that were reviewed
Full size table

In the following paragraphs, we discuss the reviewed medical and popular literature according to topics raised by feminist writings on sex/gender in health/medicine.

Is it possible to separate the effect of sex and gender on health?

Although it uses the word “gender”, GM focuses mostly on biological sex, stressing biological differences between the sexes in physiological and pathological conditions. However, this division ignores human complexity and the criticism of determinist models of sex differences highlighted by feminist thinkers since the 1990s [3] and subordinates the critical concept of gender to the biological concept of sex.

Many behavioral, psychological, and social variables correlate with sex category (being female or male). It is therefore often impossible to distinguish the contribution of these factors (i.e., gender) from that of biological variables (i.e., sex) to observed health differences between women and men. In addition, gender-related behaviors and experiences were shown to affect biological qualities thought to stem from sex category, such as levels of sex hormones, making the separation between sex effects and gender effects even more difficult [5, 44,45,46,47].

Indeed, many unacknowledged factors may mediate ostensibly sex-driven differences. For example, GM publications quote observational studies according to which women suffer from more cardiac sequalae after acute coronary syndrome (ACS) [17, 27]. However, a recent study demonstrated that gender roles, such as being the primary provider, employment, and household responsibilities, rather than sex, are those associated with prognosis after ACS [48]. Gender associated behaviors were shown to influence seemingly sex related differences in osteoporosis [49, 50] and melanoma [51, 52]. Researchers have shown that sex related differences documented in laboratory animals can stem from behavior and living condition and not from biological differences [46]. Thus, sex differences are often caused by other variables, that correlate with the sex category. Searching for these variables and their significance to health, instead of using sex as a proxy for their values, would benefit personalized medicine [6].

Feminist researchers pointed out that research often builds on a pre-assumption that sex differences in the brain exist [44] and that arguments about alleged sex differences that echo cultural stereotypes receive public attention [53]. It was shown that sex differences in the brain are often context- related, and change with time and circumstances [7, 47]. Of note, mothers were shown to behave differently towards male and female babies [54], implying that the brains of women and men are exposed to different stimuli from an extremely early stage of development.

While sex and gender are regarded as two separate entities [12], biological qualities of sex such as sex hormone levels are altered by gender related experiences and behaviors such as nurturing, competition and sexual activity in both men and women [55,56,57]. This suggests that social, material, and cultural factors likely contribute to some of the differences between men and women in health outcomes. It also suggests that addressing gender disparities is essential to improve health outcomes for women, and that both epidemiological and basic research should address the numerous social factors which differ between men and women. Gender disparities and their relation to health are addressed in a minority of the GM publication we reviewed [22, 28] and are mentioned in working field 2 of the EUGENMED report [12], but the vast majority of publications do not address gender issues. The EUGENMED workshop dedicated to basic research discusses biological sex alone, and does not acknowledge the data concerning the entanglement of biological sex and gender, nor does it call for research on this subject [12]. Moreover, some IGM officials explicitly state that “gender medicine is not feminist, it’s about real science” [58], thus denying the political and scientific origins of the GM project.

Exposure to physical and sexual violence in childhood and adulthood have a profound and prolonged impact on many women’s lives. Although violence is generally under-reported, the United Nations reported in 2012 that between ten and 40% of women worldwide experienced sexual violence during their lifetime and between seven and 68% experienced physical violence [59]. Studies have repeatedly shown the association of childhood abuse with cardiovascular [60, 61], autoimmune, metabolic diseases [62], chronic pain [63,64,65] and with mortality in women [66]. Studies discern long- lasting biological changes in abuse survivors such as increased pituitary stress response [67], increased inflammation [68] and even DNA changes such as decreased telomere length in leukocytes [69] and epigenetic changes in the brain, which can be transmitted to subsequent generations [70]. These gender-related life experiences often go unnoticed in the public sphere and in healthcare systems [71], and may mediate many seemingly sex differences in health.

Depression and anxiety are twice as common in women than in men. Abuse and violence increase the risk of depression, anxiety and post-traumatic stress disorder [72,73,74] mediated by chronic biological changes in multiple cellular and molecular components of brain function [75]. Failing to address the causative role of gender-related violence and discrimination in women’s mood disorders results in women being labeled “emotional” and “unstable”, bolstering discrimination and the silence surrounding gender-related violence. The GM studies and policies we reviewed refer to violence and childhood abuse only marginally, and do not address violence and abuse when discussing mood disorders [12]. The Israeli GM society, led by the former IGM president, states that trauma is less common in women on its webpage, reflecting a lack of understanding of the prevalence and consequences of childhood abuse and adult-life violence experienced by women [76]. Only one IGM member, Gillian Einstein, addresses violence in her scientific work [77] and public appearances.

Unfortunately, we do not fully understand the long-term health consequences of abuse and violence in women. Likewise, specific diagnostic and therapeutic interventions are not being developed. GM does not address these important issues, nor does it mention the urgent need to improve our understanding of the long-term health consequences of gender-related violence.

Some perceived sex differences in health may arise from diagnostic criteria that do not account for gender differences in manifestations of diseases. For example, depression in men may be overlooked when manifested as alcohol and substance abuse [78, 79]. Gender appropriate diagnostic criteria of osteoporosis improves its diagnosis and treatment in men [80]. Autism in women was shown to be underdiagnosed, probably because the tendency to internalize problems and camouflage social difficulties, as well as gender appropriate repetitive interests are common in autistic females [81]. These examples demonstrate that simply focusing on sex differences in epidemiology, without considering complex interactions with gender, can result in under-diagnosis and inappropriate treatment in both men and women.

Is there a binary division between the physiology of women and men?

Dividing men and women into two biological categories with different features and qualities constituted the basis for women’s oppression throughout history [82, 83]. Several GM publications assume the existence of biological differences between male and female brains, cognitive abilities, and emotional expressions, attributing these to biological factors such as sex hormones [36, 37]. However, scientific evidence shows that even when a statistically significant difference in found, considerable overlap in the distribution of measurements of single variables (e.g., specific psychological qualities and cognitive abilities) between the sexes exists [5, 6, 84]. For example, an extensive review of 26 meta-analyses looking for sex differences in psychological and cognitive traits found that, for almost all the traits studied, differences were close to zero or small and a considerable overlap existed [85].

In addition, when multiple variables are tested simultaneously in female and male brains, a mosaic distribution of “feminine” and “masculine” qualities across variables is found [7, 51, 86, 87]. This means that in an individual brain, each variable tested shows its own degree of similarity to the phenotype more common in females or in males, so that varying degrees of “femininity” and “masculinity” are found across variables in each person. Mosaic patterns were seen in brain structure on functional MRI, when assessing psychological traits by questionnaires [86], and even when assessing cellular brain structure postmortem [88]. Mosaic pattern are also seen in the effect of external stimuli, like stress, on brain function [89]. These important data shed light on the complex interactions between biological sex, the environment, and the brain, and highlight the fact that it is impossible to categorize human brains as ‘male’ or ‘female’. Of note, the groundbreaking study that delineated the brain mosaic theory was firmly rejected by the former IGM president [38].

Listening and learning from other disciplines and from women themselves

The women’s health movement empowered women to learn and share their health-related knowledge. The revolutionary book ‘Our Bodies Ourselves’, written by women for women, cherished women’s experience and challenged the authoritative position of the healthcare system. This enabled women to expose misconceptions and prejudice in medical practice. GM is practiced and discussed by physicians and scientists. In our review of GM work we did not find studies regarding women’s concerns in health, not a call for such work. While GM focuses mainly on cardiovascular health and diabetes [12, 18, 22, 26,27,28, 30], it is plausible that women from diverse backgrounds have different health concerns and priorities. The EUGENMED project involved patient’s organizations, but not feminist organizations, as stakeholders [12]. Empowerment of women regarding their health is also absent from GM discussions and recommendations.

Intersections between gender, oppression, and racial discrimination

Poverty, discrimination, economic insecurity and ethnic conflicts profoundly affect the epidemiology of common diseases and treatment outcomes [48]. These adversities generate chronic stress and affect nutrition, physical activity, exposure to pollution, access to healthcare and more. The capitalistic system generates and broadens economic inequalities between countries worldwide and within states and societies. “Black feminism” and intersectionality theory demonstrate how race, class, ability, and appearance interact with gender to generate privilege and discrimination [90]. GM publications recognize the effect of poverty and racial discrimination on cardiovascular risk [12, 28], however a call to improve and study minority women’s health is lacking. Minority women in the US, Canada, Israel, Europe, and Australia report discrimination within healthcare systems and discriminatory institutional policies and stigmas, with negative effects on their health [91, 92]. Gender discrimination in healthcare is suggested by the findings described in several of the studies we reviewed [16, 18,19,20, 23, 27]. For example – a study found that women undergoing hemodialysis in Austria were less likely to be treated via a vascular shunt and less likely to be referred to kidney transplantation [16]. Other studies showed that women with type 1 diabetes [20] and women hospitalized for heart failure [27] were less likely to be treated per current guidelines, that women were at higher risk for acute ischemic events in a cohort of patients after cardiac catheterization [19], and that women with type 1 diabetes were more likely to suffer hypoglycemia and severe hypoglycemia when treated in clinical trials of galgarin insulin [18]. Discrimination in healthcare practices and access to medical and social services may contribute to these and other [23] findings, however only 1 article [27] mentions this possibility. A discussion regarding the need for further studies looking specifically at discriminatory practices is also lacking. Racial discrimination in healthcare is not discussed at all in the publications we reviewed, and even refuted when faced with findings regarding inadequate treatment provided to Arab minority women in Israel [24].

Discussion

The “Me-too” protest against sexual violence and the “Black Lives Matter” movement reminded us that gender related violence and racial discrimination are prevalent even among seemingly liberal institutions in western societies. These uprisings share values and practices with the feminist movement, empowering women and minorities and cherishing their voices and perspectives. They teach us that real change is accomplished only by questioning the practices, interests, and power-structures of institutions.

GM has brought the issue of sex/gender and general health to the forefront of popular and professional discourse, appropriating, and mainstreaming the discussion that was initiated by the feminist women’s health movement in the 1960s. This process has obvious advantages and opportunities, such as raising awareness of health professionals, institutions, and regulatory agencies to gender differences in health, allocation of funds to research on gender and health, and better designed pharmaceutical studies. However, this mainstreaming has been accompanied by the return of professional dominance, while the voices of feminist activists go unheard. Moreover, GM ignores important scientific progress, made by feminist scientists, regarding the complex associations between sex, gender, and health. By stressing the biological division between sexes, on the one hand, and under-representing the toll of violence, oppression, ethnic conflicts, and discrimination on the lives and health of women, on the other, GM accepts conservative positions on sex and gender and reaffirms the current practices of healthcare systems worldwide. Generally, it does not posit poignant criticism to mainstream medicine, and the topics studied tend to avoid more contested health issues such as chronic pain syndromes, sexual abuse, ethnic conflict, the health consequences of beauty standards, and others.

A way forward

Feminist scientists have shown that much can be achieved by studying the mechanisms linking biology, gender, and society. A continued effort in this direction is required to improve our understanding of these mechanisms, and to implement this knowledge into clinical practice. An approach that integrates feminist epistemology and methodology into the study and practice of medicine and strives to understand the complexity of gender can improve the health of both women and men [79, 80] worldwide. Feminist activists should work together with physicians to re- define “Gender Medicine”, prioritize research and policy topics, and participate in the design of clinical studies. Efforts should be made to listen to diverse women, learn about the health challenges they face and incorporate their priorities into policies and studies. Studies that critically examine healthcare systems and the bio-scientific world for discriminatory practices and blind spots, and studies that examine the health toll of diverse forms of gender related violence and oppression should be encouraged.

Conclusion

Our review of the IGM/ ISGSCM indicate that while their work focuses on sex differences, it neglects the influence of gender, namely the social aspect of being a woman or a man, on biology, physiology, and health. We found that for the most part, their writing ignores the effect of gender norms, gender-related behaviors, and gender-related violence on biology and health. Moreover, it endorses a binary vision of 2 distinct sexes with different biological qualities, while overlooking the evidence that indicate a more complex social and biological reality. Indeed, the IGM/ ISGSCM work may improve some aspects of women’s health, however we should aim to promote a wider approach to gender and medicine – one that studies complex interactions between society and biology and that tackles difficult subjects such as debilitating chronic pain syndromes, violence, and health concerns of racial minorities. We believe that integrating the achievements of the IGM, those of the feminist women’s health movement and of current feminist scientists and activists can bring about a deep and meaningful change in the health of women worldwide.