Eve's Rib: The New Science of Gender-Specific Medicine and How It Can Save Your Life

Book by Legato Marianne J

Chapter 1

Eve's Question: "How Am I Different from Adam?"

Unless they are focusing on the reproductive system, most doctors have a tendency to treat patients as though they were all the same sex: male. We consider patients' stories of their illnesses, examine their bodies, and interpret their laboratory tests as though gender were irrelevant. We even write prescriptions the same way, seldom considering patients' size or body composition, let alone sex, to determine how their bodies will process and use a particular drug. Even our understanding of what makes men and women different has been simplistic. (Many doctors ascribe it all to hormones, which is only partly correct.) In short, we've practiced medicine as though only a woman's breasts, uterus, and ovaries made her unique--and as though her heart, brain, and every other part of her body were identical to those of a man. It's not that the profession is overrun with poorly educated sexist practitioners. For the most part, rather, it's the way we have been educated, as though women were simply small men and data we have about the male body were the standard for both sexes. Most of the information doctors use in diagnosing and treating disease was gathered almost entirely from research on males. Remarkably, it's only recently that medical science has begun to grapple with the complex factors that define a person as male or female.

The notion that women and men are essentially interchangeable isn't new. If you want to know what a culture holds to be most important and true, read its myths. Consider the story of Adam and Eve. As the crowning glory of the newly created world, God transforms some clay into the first human--a male, perfect in every way. In spite of the abundant richness of Paradise, however, Adam is lonely. Consider God, on the fifth day, taking pity on Adam. He puts him into a deep sleep, takes some tissue from his side, and fashions it into a woman. It's not only a biblical tale, it's also a medical fable, and an eerily prophetic one at that; it describes the first anesthesia, major surgery, and cloning of a new individual. More important, it tells us that Eve is literally derived from the stuff of Adam. Apart from their reproductive biology (which is admittedly unique for each, a fact with which the story's author never grapples), by definition Adam and Eve are identical: Eve is simply a smaller version of Adam.

Still, she is different enough, apparently, to want to explore beyond the boundaries set for them both: she wants more information; she wants answers to questions that only she has formulated. She tempts her hapless mate into an ill-fated collaboration to acquire that knowledge (which, she is assured by Satan, will give her more power over the world around her)--and they are expelled from Paradise, condemned to a life full of effort, pain, and all the other assorted ills of the human condition. Although we can't know precisely what she wanted to ask, I've always imagined that one of her questions was this: "How am I different from Adam?"

Eve may have brought about our exile from Eden, but perhaps she set the precedent for a minor medical revolution as well. The fact is, women have never really accepted the way doctors do business. All too commonly, when a woman would report to her doctor that a medicine made her palpitations worse instead of calming them, or that the pain from her heart attack had centered in her stomach rather than in her chest, he might simply tell her, "I've never heard of that" (or in an academic medical center, the more formal "We don't see that"). He might add to himself, Your reactions are obviously the result of some emotional issue. I can't take your complaints--or you--seriously. But thankfully, women have continued to ask their questions, and more and more they are insisting on answers.

I met some of those women personally for the first time in 1992, when I left my laboratory to go on a nationwide book tour publicizing The Female Heart: The Truth About Women and Coronary Artery Disease, which I wrote with Carol Colman, a medical journalist. In ten days I spoke with hundreds of women about their experiences with coronary artery disease and the important ways these experiences differed from those of male patients. They told me a shocking number of stories about doctors' dismissing them as hysterical or "anxious" when they were asking for help with what turned out to be their first heart attack. Every time I gave a talk, I was met with a barrage of challenging questions for which I had no answers. Those ten days with these women, who were so hungry for information about their particular needs and their unique experiences, changed my life. At the end of that trip, I returned to my fully funded laboratory, locked the door, and gave the key to the scientist next door.

My own research on coronary artery disease had shown that males and females experience that disease very differently; now I wondered, might the experience of other illnesses besides coronary artery disease differ between men and women? For that matter, what about differences in normal function? What if the biological sex of a person affected all the baseline measurements and standards that are accepted as "normal" for a healthy human? If it did, doctors would have to modify the way they've always thought about medicine. Our society might even have to construct entirely new strategies for preventing and curing disease, strategies that would emerge from a new awareness of the fundamental differences between men and women.

SEX OR GENDER: WHAT ARE WE TALKING ABOUT?

What is it, precisely, that makes people either men or women? It's more than just hormones; it's a whole variety of things, and scientists are only just beginning to tease out the various ingredients of what biological sex is, and why males and females are different. But the complex interplay of genes and hormones that define biological maleness and femaleness is only half of the story. Males and females don't exist in a vacuum, and the way they develop and thrive--or fail to thrive--is a very real consequence of the societies and cultures in which they find themselves. Biological sex is overlaid by the roles, rules, and expectations society sets for its members. The combination of our biological sex with the impact of our environment on our health and behavior as men or women is called gender. Health is affected as much by environment as by genes and hormones, and it can be virtually impossible to determine whether biology or the way people live in their particular communities is responsible for their health. If Muslim women get malaria less often than Muslim men, is this because their immune system has some innate, sex-determined ability to fight off infection, or because they are required to wear clothing that conceals them from head to toe--and thus protects them from the bite of the mosquito carrying the malarial parasite? If African women get trachoma (a parasitic infection of the eyes that destroys vision) more frequently than African men, might it be because women spend much of their day at the river's edge, where the parasite lives, doing the family laundry and socializing with other women of the community? Teasing out these differences is one of the most complex and difficult challenges modern science faces.

WHY HAVE RESEARCHERS STUDIED ONLY MEN?

Like every other scientist trained in a top-rank medical center, I was taught, and had accepted, that the results of research done in males were applicable to both sexes. In anatomy laboratory, none of my instructors thought it important to point out whether our cadaver was male or female, except when we studied the reproductive organs. I didn't even entertain the idea that there might be significant differences between the two beyond the reproductive system. In a revealing monograph, the National Academy of Sciences' Institute of Medicine calculated that fully two-thirds of all diseases that affect both men and women have been studied exclusively in men. As a result, the models not only of how humans function normally but also of how they experience illness are essentially male. This assumption that men and women are so alike that it's not important to study women directly has dominated the way scientists do biomedical research and the way doctors practice medicine. Until very recently, everything about American health care, from research protocols to public health policies, reflected an intellectual mistake of astounding proportions, one that undoubtedly has affected the health and the lives of many women over the years.

How in the world did this happen? The answer is complicated. It is not simply that men, who have traditionally dominated the worlds of academic medicine and scientific research, didn't care about women or thought they were unimportant. In fact, many of the dictates that restricted medical research to males were the result of an effort to protect women--particularly premenopausal women, whose reproductive abilities were of primary concern--from the risks of experimentation. (Scientists seldom if ever worried about a young man's reproductive potential: society still measures men principally by what they achieve, and women by their ability to conceive and bear children.) Researchers know that damage done to a fetus conceived during a clinical trial is not only an ethical issue; it can have potentially disastrous legal and economic implications if the child is born malformed.

This philosophy of protectionism, by the way, was reinforced by the publicizing of Nazi atrocities during the Nuremberg trials, particularly the Doctors' Trial, which detailed the experiments done on concentration camp inmates (including children) in the name of medical science. That exploitation was not exclusively the work of fringe elements in the medical profession. One of the doctors, Paul Rostock, was the dean of the University of Berlin School of Medicine and chief of its department of surgery. Before the war, he had been an inte...