Friday, August 13, 2010

How Medicine Needs Critical Thinking Derived from Investigating Sex Differences

Medical education begins as a reductionistic endeavor. The 'one size fits all' aide in mastery of concepts and principles. The reality of clinical care is that one size does not fit all. Not one for every human; one for every man; one for every woman.  The impact of clinical exposure is that clinicians gain a video-library in their head of symptoms. From the first textbook description on angina - we meet patients with exertional jaw pain ("I get tired while eating'); to neck pain ("it feels like someone is strangling me') to fatigue, tachycardia, nausea and pressure. So we explode our differential diagnosis with these real-life manifestations of disease. In the ideal, we then can use (or design studies to find) data and evidence on how best to proceed in diagnosis; treatment; outcomes and prevention of complications. The binary evaluation of information by sex - men/women, affords an opportunity to practice how to consider uniqueness in patient specific ways.
       Clinical reasoning implications from evaluating sex differences is seen in evaluation of the literature (what applies to whom and when?); in tuning your ears for how people present to you with symptoms ('classic chest pain' vs fatigue); deciding on treatment (what is best for whom); avoiding complications and adverse effects and investigate unanswered question in science as well as discovering new ways to delivery better care and improve outcomes.
     Show me the data! - the Institute of Medicine functions as an evidence based body that evaluates various topics and is a terrific resource. Congress authorizes the IOM to explore issues; they convene a panel of experts who deliberate for several years; these experts then report on all available evidence on a topic. In showing the impact of sex and health, the 2001 report entitled Exploring the Biological Contributions to Human Health: Does Sex Matter? responded with a yes, it does.
So, what do we mean by sex and gender health disparities?
              Sex and Gender Health Disparities - evaluation of the unequal burdens of disease in morbidity ( dysfunction) and mortality (death) that result in unequal health outcomes.SGHD can occur amongst women ( e.g cardiac disease) or amongst men(osteoporosis)
And in sex/ gender medicine - we tend to focus on the context (not just a disease located within a patient) which is in concert with the the definition of comprehensive girls/women's health
              Comprehensive Women's Healthcare- patient centered, whole patient care that includes the lifespan ( womb to tomb) and non-reproductive and reproductive healthcare within the context of her life and world. This comprehensive approach is useful for all patients, but Women's health is often framed as reproductive health only care -yet the reproductive span is shorter than non-reproductive.
This very cool graphic is from Dr Sarah Hean in her article Learning theories and interprofessional education: a user's guide. Source Learning in Health & Social Care. 8(4):250-262, December 2009.

Tuesday, July 20, 2010

Which is the Correct Term - Sex, Gender, Both?? How Medicine Can't Yet Accurately Answer The Question

Two dots, the Area Under the Curve, a Venn Diagram, a Double Headed Arrow - How to define sex and gender?
Standard Definitions: 
Sex The biologic definition is one that refers to the classification of living things, generally as male or female according to their reproductive organs and functions assigned by chromosomal complement. The biologic definition various from the psycho-social, the cultural and other approaches.
Gender The biologic definition refers to a person’s self-representation as male or female, or how that person is responded to by social institutions based on the individual’s gender presentation. Gender is rooted in biology and shaped by environment and experience. Current work is now moving to gender being defined as agency (the ability to take an action and do something) versus expression (as in nurturance or able to express emotional experiences) rather than male/female.
Sex/Gender Definition – In health care these are complex concepts that are influenced by cultural, social and political contexts-which cannot be equated or reduced to simply biology and culture.
Sex/Gender Health Differences – a field of study that examines different health outcomes as a result of sex and gender resulting in essential information about disease activity, susceptibility and provides important clues in pathophysiology (what processes are not working correctly) and in developing new devices and treatments. Sex hormones are only one of multiple factors that contribute to sex and gender differences.

 1. Sex can be viewed as a polar entity (for purposes of this current discussion, will defer on a discussion on trans health - although it reinforces the continuum approach.) Just as with computer codes - "0" and "1", male and female can be considered discrete, autonomous endpoints. A way to categorize into piles. Gender, in Medicine, is often framed as the environment's impact of femaleness or maleness. Yet, information about neuroplasticity of the brain reveals that our world can physically (neurologically) change us. So our experiences creates biologic change within us. That is good news when it comes to rehab after a stroke, but this influence can be even more subtle. So, reductionistically, sex and gender can be mathematical data points.
     So, that's one definition and framework but there are more.Sex/gender can also be viewed as 2) biospsychosocial, 3) cultural, 4) intersectional, 5) on a continuum, 6) interchangeable.
2. Biopsychosocial - that Venn Diagram - looks at the psychoanalytic components of sex/gender. What are the social and cognitive processes? How does self-labeling and identity formation play a role?
3. Cultural - the ultimate in contextual, there are those that argue that culture is a lens for all that we do and how we see ourselves, hence sex/gender are cultural elements
4. Intersectional - this one is a bit more complex. It is based upon the intersection of biology and culture whereby power and resources are available differentially. The 'haves and have nots' of sex/gender. A great example is aging. When we talk about the issues of elderly, we are more often talking about issues of women (as women sadly outlive men!) But we are also talking about issues of poverty. The endpoint of the 73 cents to a dollar of economic disparity for the same work, results in aging women having scarce resources. We see this in an elderly lady choosing food over medications, for example. In case the 'haves not' seem inherently and uniquely female, recognize that one of men's 'have nots' is a tradition of accessing health care!
5. Continuum - this definition focuses upon the variability and range of sex/gender in manifestation and expression. It also warns that our polar, on/off switch of sex/gender can blind us to fluidity and genetic diversity.A good example is that of Kinsey and sexuality - prior to his work, heterosexuality and homosexuality where viewed as two discrete things (back to the scientific on/off switch) As a result of scientific inquiry, the continuum of sexual attraction was uncovered.
6. Interchangeable - in some fields, sex and gender are viewed as synonymous and interchangeable.

So, what's the 'right' answer in Medicine? The answer is, we don't yet know. Clearly, uterine cancer is a sex-specific issue. Intimate partner violence appears to be a gender based issus. But the role of sex and gender in science, despite the field being 20 years old, is still not well delineated. The right answer may be that sex/gender include all of the definitions and that we need critical work to flesh out the impact and answers.


Where Does Sex/Gender Fit in Health Disparities? - Some Definitions:

  • Health disparities – “Disparities in health are defined as unequal burdens in disease morbidity ( lowered function due to illness)and mortality (death)rates experienced by ethnic/racial groups as compared to the dominant group (USDHHS, 2000). ” "Disparities in health care are defined as racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences and appropriateness of intervention" (Smedley, Stith, & Nelson, 2002, p. 4).Causes of disparities in health care relate to quality and include provider/patient relationships, health providers of the future, provider bias and discrimination, and patient variables such as mistrust of the health care system and refusal of treatment” Although race/ethnicity were most written about health disparities can seen in a number of patient groups including women.
  • Sex and Gender Health Disparities - evaluation of the unequal burdens of disease in morbidity ( dysfunction) and mortality (death) that result in unequal health outcomes.SGHD can occur amongst women ( e.g cardiac disease) or amongst men(osteoporosis.)
  • Culturally Effective Health Care – health care that addressing biopsychosociocultural elements on wellness and disease. It is appropriate to the individual and their world. Knowledge about culturally diverse attitudes, health practices, physician bias, barriers and skills to increase awareness of ‘blindspots’ are essential for optimal health outcomes. The culture of sex/gender, in some ways is more difficult than others, as there is an assumption that the culture of sex/gender is something ‘everyone knows.’ Seasoned clinicians are aware that issues about family role, body image as well as anatomic and physiologic differences are important to investigate, reflect and act upon in order to optimize health outcomes.

Friday, April 9, 2010


Welcome to our site! Having worked in the field of cross cultural medical education for over twenty years, I have seen the ever-changing terminology to our work. First there was diversity, and then came cultural competence, now health disparities. So what do I mean by cross cultural effectiveness in health care? I have defined this as the process between health care provider and patient that consists of awareness of difference (of self and others), knowledge of culturally relevant attitudes, experiences and worldviews and skills to deliver excellent and appropriate health care. Although the most MESH headed term is cultural competence and efforts to evaluate and assess impact are important, I think medicine needs to focus on advancing the process of care delivery, not just the product. Regrettably, cultural competence is sometimes viewed as the checklist of things I need to know about a group - not the nature of the interaction. It is far easier to memorize exotic sounding health beliefs. It is harder to reflect in the mirror, 'how to I come across?" "What assumptions am I holding?' It may be even harder still to create safe spaces within medical education and training to nurture this work.
    I also give the caveat that cross-cultural effectiveness within the patient-doctor relationship is a myopic snapshot of the entire picture and that an ecological model needs to be considered in designing educational venues and addressing the challenges.