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SEX BASED DATA IN HEALTHCARE. DOES IT MATTER?



is snow clearing a gender-neutral task? in canada, winter fluctuates in intensity, but some form of snow is a consistent element.the policies guiding this seemingly routine municipal duty inadvertently carry gender biases that resonate far beyond the streets. While most municipalities prioritize snow clearing based on heavily traveled roads, a published study reveals a nuanced perspective. according to a global study, on average, the likelihood to use public transport among females is about 6% higher than among males. gender difference in the use of public transportation is highest among older adults, where women are, on average, 26% more likely to use public transportation in this age group. and women are also on average 25% higher likelihood to walk to work than men.1 


in single car families, men are most likely to prioritize access to a car. women are also more likely to be responsible for pushing baby strollers (usually on uncleared sidewalks), and also more likely to be primary caregivers (taking kids to school, parents to health appointments, etc.) consequently, snow clearing policies, when prioritizing roads over sidewalks and transit stops, unintentionally favour the commuting preferences of men.


the connection between snow clearing and health might seem unclear, but it serves as a tangible example of persistent gender disparities that extend beyond seemingly unrelated fields. consider groundbreaking scientific discoveries attributed to men, such as the DNA double helix structure credited to James Watson and Francis Crick, overlooking Rosalind Franklin's crucial discovery of a double helix (Watson and Crick discovered one helix). Dr. Nettie Stevens, in 1905, challenged conventional beliefs about sex determination, demonstrating that the Y chromosome plays a pivotal role in male development. despite Stevens' pivotal findings, her mentor E.B. Wilson received credit for the discovery. these instances underscore how women's contributions have been consistently overshadowed, reinforcing a narrative of male-centric scientific achievements.


how does this connect to sex disparities in healthcare? Gender disparities, unfortunately, are ingrained in societal norms. women's overlooked contributions in scientific realms mirror their persisting underrepresentation and exclusion in healthcare. breaking the ice on gender disparities in healthcare reveals a complex web of biases that impact women's well-being in profound ways, and cancer care is no exception.


Heart Health as an example

women face a troubling trend of underdiagnosis when it comes to heart attacks. Traditional diagnostic criteria have often been based on male-centric symptoms, leading to a dangerous oversight of women's unique cardiac manifestations. women experiencing heart attacks may present with symptoms that differ from the classic male symptoms, such as chest pain. unfortunately, these differences can result in delayed or underdiagnosis, putting women at increased risk of adverse outcomes that include death. the Heart & Stroke Foundation recently published a report, System Failure, that documents the inequities that threaten the heart and brain health of women in canada. (learn more here)


the terms ‘sex’ and ‘gender’ are not interchangeable. ‘sex’ refers to the biological differences between males and females, and encompasses sex organs, endogenous hormones and chromosomes]. ‘gender’, however, is a sociocultural construction that encompasses the roles, norms and behaviours expected for males and females in society, which may or may not correspond to their sex.


the influence of both sex and gender on cancer susceptibility, progression, survival, and treatment response is evident. current approaches to cancer care often overlook the significance of gender and sex.  viewing the patient through a sex and gender lens is a first step toward personalized care, which has been a hot topic in cancer since the addition of precision medicine. And evidence suggests that women often do not receive the same level of treatment for cancer as men. this is unsurprising as women have historically been excluded from clinical trials, leading to a focus on male physiology in research and medical attention. the diagnosis, treatment and prevention of disease originates from studies carried out mainly on male cells, male mice and men. 


although there has been an increase in female participation in clinical trials over the past few decades, women remain underrepresented across all clinical trials phases (including preclinical and early-phase trials and animal studies), creating sex-specific gaps in medical knowledge. this routine exclusion of women from clinical trials not only puts their health at risk but also perpetuates disparities in our understanding of drug effects and real world treatment outcomes, including drug development undermining the accuracy and effectiveness of pharmaceutical interventions (this is due to a lack of female representation in preclinical and early-phase clinical trials, in animals and humans). the clinical evaluation of drugs also often fails to consider gender differences, impacting dosing, safety, and efficacy.


sex-specific data is critical for understanding how drugs interact with the male and female body differently, yet this information is often neglected in drug development and reporting. clinical trial data generated in men does not necessarily extrapolate to women, who exhibit a 1.5 to 1.7 times greater risk of experiencing adverse reactions to drugs. paradoxically, because women also tend to exhibit more adverse drug reactions (ADRs) they also face higher hospitalization rates, requiring increased access to healthcare services. because drugs are developed and tested with the assumption that women are just smaller men, or a subtype of men,  the study of one sex is generalized and applied to both. a 2016 study found that male and female cells influence immune responses, resulting in sex-specific outcomes from infectious and autoimmune diseases, malignancies, and vaccines. what this actually translates to is that women are being treated (and sometimes overtreated) with these same drugs and dosage, but with less efficacy and more toxicity. other drugs that have failed in any clinical trial phase for men could have been effective for women and do not go through further development and approval process’. this hampers our ability to identify important differences that could benefit the health of all. 


men and women are fundamentally different when it comes to health and disease.4

a comprehensive and sex-transformative approach to the cancer field is crucial. this includes actions such as (but not limited to) female specific research, collecting sex-disaggregated data, studying emerging cancer risk factors that disproportionately affect women, and establishing economic frameworks recognizing the contributions of often unpaid women serving as caregivers. this would ensure responsiveness to the diverse needs of women in various roles – as healthy individuals engaged in cancer prevention, individuals living with and beyond cancer diagnoses, caregivers, patient advocates, healthcare providers, cancer researchers and policymakers. 


these disparities extend beyond seemingly mundane activities like snow clearing, without including women in the lexicon we continue to emphasize that men are the standard by which we understand women’s health and needs.


REFERENCES

  1.  Goel, R., Oyebode, O., Foley, L. et al. Gender differences in active travel in major cities across the world. Transportation 50, 733–749 (2023).

  2.  What is gender? What is sex? Canadian Institute of Health and Research (CIHR)

  3.  Vera R, Juan-Vidal O, Safont-Aguilera MJ, de la Peña FA, Del Alba AG. Sex differences in the diagnosis, treatment and prognosis of cancer: the rationale for an individualised approach. Clin Transl Oncol. 2023

  4.  Clayton JA. Studying both sexes: a guiding principle for biomedicine. FASEB J. 2016  

  5.  Christine M. Madla, Francesca K.H. Gavins, Hamid A. Merchant, Mine Orlu, Sudaxshina Murdan, Abdul W. Basit, Let’s talk about sex: Differences in drug therapy in males and females, Advanced Drug Delivery Reviews, 2021

  6.  Zopf Y, Rabe C, Neubert A, et al.. Women encounter ADRs more often than do men. Eur J Clin Pharmacol 2008

  7.  Zucker I, Prendergast BJ. Sex differences in pharmacokinetics predict adverse drug reactions in women. Biol Sex Differ. 2020

  8.  Klein, S., Flanagan, K. Sex differences in immune responses. Nat Rev Immunol 2016

  9.  O.Ginsburg, et al. Women, power, and cancer: a Lancet Commission. The Lancet December 2023.

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