Literature Review on Effective Sex- and Gender-Based Systems/Models of Care

January 30, 2007

BACKGROUND

This section of the report includes a brief discussion of some recent findings related to health-related differences between men and women. These include biologically and physiologically driven differences in disease symptoms and rates, as well as gender-based differences driven by norms, socialization, or lifestyle. This section of the report is not meant to be a comprehensive listing of such differences (see the two volume medical textbook "Principles of Gender-Specific Medicine," Legato, 2004, for such a discussion), but rather is intended to provide a contextual background against which to understand both the importance and complexity of gender-based medicine. We also provide a brief discussion on how issues of quality relate to gender-based care.

Two of the primary sources of medical differences between men and women are biology and physiology. The most obvious sex differences in these categories relate to size, hormones, and the reproductive system, but there are many other such differences that can impact overall health. The result is that men and women may experience the same diseases at different rates or with different symptoms, or they may experience different kinds of illness altogether. Here we provide a limited number of examples in which women and men differ in disease rate, expression, onset, or severity. Many of these examples are attributable to variations in hormonal cycles. Others are driven by other factors or have not yet been fully explained:

• Men and women are both at risk for cardiovascular disease, however "the onset and development of coronary heart disease (CHD) in women are closely related to ... ovarian hormones" (Penco, Fratine, Romano, & Novo, 2003).
• Men have higher blood pressure than women through middle age, "but after menopause, systolic blood pressure increases in women to levels even higher than those for men" (Kim, Alley, Seeman, Karlamangla, & Crimmins, 2006).
• Women are at a significantly higher risk for autoimmune disease. This may be because "periods of hormonal fluctuation in women may allow a greater plasticity of immune responsiveness, thus altering susceptibility to disease" (Shames, 2002).
• Women's hormonal cycles also lead to differences in the expression of pain: "Pain sensitivity varies with the stage of the menstrual cycle; pain threshold and pain tolerance are higher in the follicular phase, when progesterone levels are low, than in the luteal phase. Chronic pain states are more common in females than in males from puberty to menopause and beyond" (Wiesenfeld-Hallin, 2005).
• While men and women bear about the same cancer burden overall, "taking all cancers combined worldwide, the distribution of burden according to gender is slightly unequal, with 53% of all incident cases, and a somewhat larger proportion (57%) of all cancer deaths experienced by men" (Bray & Atkin, 2004).
• Some cancers are more prevalent in women, however. For example, thyroid cancers are more common in women than men. While "the presumption is that estrogens play a role, no clear evidence has yet emerged" (Adlersberg & Burrow, 2002).
• The study of Alzheimer's disease (AD) has found several differences between the sexes: "Women with AD were more likely to exhibit severe cognitive impairment than men. ... Men [are] more likely to exhibit behavioral problems (e.g., wandering, verbal and physical abuse, and other socially inappropriate behavior). In addition, studies have shown gender differences in the psychiatric manifestation of AD, with women more likely to have depression and multiple psychiatric problems" (Buchanan, Wang, Ju, & Graber, 2004).
• Some diseases tend to affect men and women at different ages. For example, "women have a later age of onset than men" for schizophrenia (Fleming, 2004).

As these examples indicate, biology and physiology contribute to significantly different rates in the expression of disease in men and women. As we will discuss in later sections of this report, if medical practitioners are not aware of and responsive to these differences, the quality of patient care may suffer.

In addition to these biologically and physiologically driven differences, the fact of being male or female leads to different socialization, expectations, and lifestyles. Thus, gender roles additionally affect and interact with health. These interactions may be even more complex than biological and physiological factors, as the direction of their effect is not always consistent. For example, some factors make women more likely to seek treatment, while others make them less likely to seek treatment. The following are some examples of the influence of gender on health:

• Women may not recognize their risk for certain diseases. For example, "women are less likely to attribute their symptoms to cardiac-related causes ... most women still do not internalize their risk from cardiovascular disease" (Azad & Nishtar, 2005). Thus, women may not seek appropriate cardiovascular care.
• At the same time, women are more likely to seek treatment for most diseases, especially potentially stigmatized diseases such as those related to mental health. These differences in willingness to seek help begin to appear early in life. One study found that "girls were more likely than boys to indicate a willingness to use mental health services" (Chandra & Minkovitz, 2006).
• On average, women report more symptoms than men, even when illness status is similar: "Women ... rated their symptoms as more severe than men did and experienced more days with a multitude of symptoms. Women had higher symptom frequencies for two-thirds of the symptoms on our scale" (van Wijk, Huisman, & Kolk, 1999; van Wijk & Kolk, 1997). It is unclear whether these differences are due to "symptom frequency, symptom intensity, or both" (van Wijk et al., 1999; van Wijk & Kolk, 1997).
• However, women may be more embarrassed than men to report certain symptoms. For example, "women are taught that bodily functions are something to be kept private and secret ... [e.g.,] bowel functioning becomes a source of shame and embarrassment [negatively impacting treatment for irritable bowel syndrome]" (Chang et al., 2006).
• Women are the primary health deciders, including taking charge of "the vast majority of routine health care decisions and responsibilities for their children" (Salganicoff, Ranji, & Wyn, 2005).
• With this responsibility comes extra burden, however. Women are more likely to be caretakers, either for young children, ill spouses, or elderly parents. Indeed, "it is estimated that the average woman can expect to spend 18 years caring for a parent, comparable to the number of years spent raising and taking care of her children" (Donelan, Falik, & DesRoches, 2001).
• Likewise, studies have shown that women experience more daily stressors than men (Matud, 2004), which could contribute to differences in disease. Women report more stress related to "social life, relationship, child, family health, and job" (McDonough & Walters, 2001). Women may experience this additional stress because they are "more reactive to negative stimuli" (Rhudy & Williams, 2005).
• Women and men engage in different types of risk activities, and their behaviors vary in important ways. For example, "men start smoking at a younger age, smoke more cigarettes per day, and report inhaling more deeply on their cigarettes than women" (Zeman, Hiraki, & Sellers, 2002).
• Women are more likely to engage in self-screening behaviors for health threats (e.g., "wives are considerably more likely to detect melanoma on their husbands than the reverse" (Evans, Brotherstone, Miles, & Wardle, 2005)), and in general place a higher value on a wide range of preventive behaviors such as "eating fruit and vegetables" and "wearing seatbelts" (Evans et al., 2005).
• Finally, women and men deal with different cultural expectations related to health, with women being subject to greater medicalization, including "the medical takeover of weight control, fitness, cosmetic surgery, and infertility, all areas where women are the primary clients" (Zimmerman & Hill, 2000).

Thus, gender, in addition to biological sex, is an important variable in understanding health and health behaviors. Gender impacts numerous aspects of how men and women perceive the need for care, report their symptoms, and experience illness and disease.

In thinking about gender-based medical care, one issue that immediately arises is the problem of how to define and measure quality care for men and women. If men and women have different health concerns and needs, then what constitutes quality care for women and men likely differs in important ways. Thus, it becomes a challenge to determine when quality objectives have been achieved, because equivalent care may not be sufficient to meet quality objectives.

The objective of quality improvement is to improve care for everyone. Sometimes this will mean treating men and women the same, but sometimes it will mean treating men and women differently according to evidence-based, gender-specific guidelines.

The next several sections of this report will examine how sex and gender impact overall quality of medical care in the United States, as well as what differences exist between men and women in experiencing medical care (including insurance coverage and costs), and how the U.S. healthcare system can more effectively incorporate sex- and gender-based differences into medical care.

Current as of March 2007