This report is part of the activity that CyberEthics Lab. is carrying out within the EU funded project PERSIST (Patients-centred SurvivorShIp care plan after Cancer treatments based on Big Data and Artificial Intelligence technologies).

After a first definition of concepts around the gender and related approaches to handle it, this report focuses on the first project findings related to a Gender Medicine approach, that is aimed to impact the health policies, the medical protocols, and the results of treatment for certain types of cancer. The final aim is to create awareness and knowledge on how gender affects health is essential and should increase.

Sex and gender indicate different concepts

First of all, a clarification of terminology, i.e. a definition and distinction between sex and gender, is fundamental to understand the concepts around which the gender analysis is developed.

According to the Cambridge dictionary, gender is the physical and/or social condition of being male or female, not so much because of biological differences, but mainly because of social and cultural differences; these differences are constantly changing, and are subject to many variables such as demographic, economic, religious, and geographical factors[1]. The WHO argues that, when we talk about gender, we are referring directly to the associated behaviours, roles, and opportunities of women and men in different societies. 

Sex, on the other hand, concerns the difference between individuals based on their reproductive organs (female, male, and/or intersex)[2].

However, it is always difficult to completely dissociate “sex” and “gender”: they often overlap, because many gender-related problems concern biological problems at the same time. Several ethical and social problems depend on inequalities between genders. In any research or gender analysis, it is always important to take that into account and to try to identify the relationships between these factors. A correct gender analysis has a particular impact on both the conceptual and the concrete level.

Gender concepts

Stated the difference between “sex” and “gender”, we should distinguish among the different definitions around the gender approach.

Gender identity[3]: the way individuals and groups present themselves and how they are perceived by others. These identities, due to specific contexts and implications, may vary according to ethnic identity, social class, and other factors.

Gender equality[3]: Gender equality is a fundamental human right and is necessary to achieve the goal of peaceful and complete coexistence, which develops in a fully human spirit.

Gender dimension[4]: this expression was used and developed in 2011 within the European Commission; it is based on the right to equality and non-discrimination, on the consideration of the rights and well-being of women, girls, LGBTIQ people, and people of any gender identity.

Gender analysis[5]: the analysis and understanding of ways and factors to identify and resolve inequalities due to differences between men and women. Established hierarchies and unequal allocation of power as a cultural element are to the disadvantage of women, who find it more difficult to assert roles of responsibility and to access economic, health and professional resources, thus suffering negative consequences in terms of lifestyle of people and well-being. 

Gender mainstreaming[6]: a strategy adopted at international level to make gender equality a reality; this means that in the design, implementation, and monitoring of standards, policies and protocols a gender overview is considered to promote equality between women and men.

Gender medicine[7]: the interdisciplinary study of how diseases impact men and women differently based on biological and social differences. Prevention, clinical signs, therapeutic approach, prognosis, psychological and social impact differ greatly according to the disease and to the patient’s gender, yet medical professionals often overlook the latter and focus only on the former.

Personalised measures to reduce discrimination in medicine

Among the previous definitions, PERSIST gender approach focuses on Gender Medicine studies with the aim of develop personalised, patient-specific therapies by analysing the ways in which gender differences affect the incidence and prevalence of a disease, its symptoms and the functioning of therapies and treatments for it[3].

This approach is based on the concept that the discriminating factors in biology and in the social, cultural, psychological, and ethnic fields between men and women are the starting points for an accurate analysis: any difference or inequality determines the possible health policies and used procedures.

Beyond biological differences

Gender biological differences are not the only ones necessary for a system of diagnosis and treatment appropriate to health rights. Alcohol, smoking, eating habits, and lifestyle, are just a few examples of external factors that can have a significant impact in gender medicine. It is a gender specific medicine that must first enter into the mindset and be perceived and accepted, then shared and applied.

Gender, in women’s health, has long been considered only with reference to reproductive factors. Since the 1990s, gender medicine and pharmacology have begun to include numerous elements characterizing the differences.

From the statistics[8] we see that the health condition regarding pregnancy, maternity, and childhood improves, but 40% of women of reproductive age (age 15-49 years) had only about four prenatal care visits during pregnancy and 38% of active women who need contraception did not use a modern method. Data on knowledge and awareness of diseases, including HIV, are very alarming: 7 young women out of 10 (15-19 years) in sub-Saharan Africa have little or no knowledge of the disease.

Ethnicity and geographical affiliation determine the social independence of women, which is equivalent to the difference in access to care. For example[8], 44% of women with low social independence had at least four prenatal care visits as opposed to 73% of women with greater social independence, a difference of 29 percentage points; in North America, breast cancer has a five-year survival rate close to 90%, while it is below 60% in many low-income countries. It is estimated that 73% of women die from non-communicable diseases. The WHO has identified six variables that underpin social independence[7]:

  • Frequency of reading newspapers and magazines
  • Education of women (completed cycle of studies)
  • Age at first birth
  • Age in the first year of cohabitation
  • Age difference with partner

Difference in education between partners. Autonomy and independence[9] from one’s partner also leads to increased information and decision-making regarding the availability and access to health services.

Another key issue is the socialized gender roles played by men and women respectively; men are less inclined to seek support and help for personal health, given their proclivity to uphold ideals of masculine courage[10]. Elements of risk, such as smoking and excess alcohol, are mainly projected onto male identity; moreover, men suffer more from stress due to the patriarchal imposition of them as heads of families, according to which men have to earn money to support the family. Prevalence of depression, a major contributing factor to hypertension and early death, is higher in unemployed men than employed men.

The role of women in the family, which is generally central, subjects them to as many dangers. A large proportion of women are engaged in domestic work, unpaid work, or informal work (an estimated 740 million women: in Africa, women in informal work make up 90%[11]), thus without health care and without access to adequate care for themselves or their children. In the professional field, women receive on average a lower salary than men for the same job, and tend to have more difficulty in taking on leadership roles. Conscious and gender-sensitive policies, such as the elimination of job discrimination and appropriate childcare, can bring great benefit to workplaces and favour faster professional growth for women.

The psychological implications of these factors are very important elements, often forgotten by health and social policies. Mental health is strongly influenced by epidemiology, risks, and tendencies typical of the female and male genders. Women are more likely to experience anxiety, psychosis, schizophrenia, and depression. Violence experienced by partners or other individuals increases the risk of depression, anxiety and suicide attempts (suicide deaths are higher in men, but suicide attempts have always been higher in women). Psychic health, in addition to determining epidemiology, affects the availability and response to some treatments (including forced sterilizations, involuntary abortions[12]).

Gender also has a major impact on physical activity habits; stress obesity, more common among women, is more likely to be affected by non-communicable diseases[13].

Gender medicine must consider all those factors starting from prevention and symptomatology before the choice of therapy or rehabilitation. The interventions necessary to achieve a therapeutic approach measured on the patient, respectful of differences, should be promoted: individual and community awareness, training of the staff involved, study and research.

Conclusions

The PERSIST project is investigating the possibility and perspective of a Gender Medicine aimed at reducing inequalities between men and women with respect to their access to medical resources, treatment, and the consequences of such treatment on people’s lives. To ensure equitable health care, it is necessary to have a comprehensive approach to the situation, to use “tailor-made” strategies, and to implement systems capable of providing a medical service that truly takes human rights into account.

Gender equality, reinforced through legal means and social habits that guarantee the freedom of identity choices by erasing discrimination, is thus one of the several conditions that can deliver a health system open to the needs of all.

A multidisciplinary approach is therefore needed, in order to see and understand the many factors that give rise to inequalities that precede health care. Indeed, the root causes of said inequalities are often situated in the culture and concepts of a society, in tradition and in the lack of adequate knowledge. Health care policies, organisations, and management must also follow an organic and complex model, capable of generating and transforming policies according to a gender sensitive assessment model[14].

A gender sensitive assessment of health services must certainly include consideration of all transgender people and the psycho-physical conditions they face. The transgender population suffers from a higher percentage of myocardial infarction[15], due to the stress of lack of social acceptance and discrimination. The same goes for LGBT people, who encounter – in addition to social stigmatisation – more difficulties in accessing health care, and therefore a progressive demotivation in the search for treatment.

Gender-sensitive policies should develop, as the WHO states[16], “equitable and gender-sensitive health systems that consider the interaction of gender with wider dimensions of inequality, such as wealth, ethnicity, education, geographical location and socio-cultural factors and their implementation within the framework of human rights”. The perspective and success of gender medicine depends on all these elements. The training of health staff and the adaptation of services should take Gender Medicine into account in order to respect human rights and preserve minorities or marginalized people.

In addition, non-discriminatory and increasingly appropriate technical and technological innovations should support Gender Medicine. Digital ethics and care ethics should therefore find a common method, based on converging principles, to understand the value of digital ethics in health care design of technology.

References

[1] Hyde, J. S., et al. (2018). The future of sex and gender in psychology: Five challenges to the gender binary. In: American Psychologist, 74 (2), pp. 171-193

[2] The Gendered Innovations website, available at: http://genderedinnovations.stanford.edu/methods/language.html

[3] World Health Organization, Breaking barriers towards more gender-responsive and equitable health systems, 2019

[4] Website of the European Institute for Gender Equality (EIGE), available at: https://eige.europa.eu/thesaurus/terms/1160

[5] http://www.euro.who.int/en/health-topics/health-determinants/gender/gender-definitions.

[6] European Institute for Gender Equality (EIGE), available at: https://eige.europa.eu/gender-mainstreaming/what-is-gender-mainstreaming

[7] Ministero della salute italiano, Il genere come determinante di salute. Lo sviluppo della medicina di genere per garantire equità e appropriatezza della cura, 2016 p. VII

[8] Demographic and Health Surveys or Multiple Indicator Cluster Surveys. The coverage of these surveys covers the period 2010-2017 and is calculated as an average of the population-weighted country values. Europe and the Western Pacific are represented by only four countries and the Americas by only eight countries in the trend analysis

[9] “Women’s social independence is strongly associated with their use of sexual, reproductive and child health care services”; report by World Health Organization, Breaking barriers towards more gender-responsive and equitable health systems, 2019

[10] Mahalik JR, Burns SM, Syzdek M. Masculinity and perceived normative health behaviors as predictors of men’s health behaviors. Social Science & Medicine, 2007. 64(11): p. 2201–2209

[11] ILO, Women and men in the informal economy: a statistical picture (third edition). 2018, International Labour Office: Geneva

[12] Drew N et al. Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. The Lancet, 2011. 378(9803): p. 1664–1675

[13] Guthold R et al. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. The Lancet Global Health, 2018. 6(10): p. e1077-e1086

[14] See the definition provided by the European Institute for Gender Equality (EIGE), available at: https://eige.europa.eu/thesaurus/terms/1217

[15] Alzahrani T et al. Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circulation: Cardiovascular Quality and Outcomes, 2019. 12(4): p. e005597

[16] World Health Organization, Breaking barriers towards more gender-responsive and equitable health systems, 2019, p. 8

PERSIST has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 875406