women’s health

On March 24, 2020, about 2 months after the pandemic really started to make a difference in the United States, I started to experience symptoms of anxiety, or so I thought. I was experiencing shortness of breath and a heavy chest; I could barely walk around the block without causing severe shortness of breath. Although this a common, and potentially deadly sign of COVID-19, I chalked my symptoms up to anxiety; I convinced myself that I was experiencing a panic attack. Constantly. FOR 7 DAYS STRAIGHT. I truly believed I was having a constant panic attack for a week straight, even when I was awoken in the middle of the night with such shortness of breath that I was afraid I couldn’t breathe anymore; I believed it was “just anxiety”.

On April 1, 2020, I received a phone call from the Boulder Public Health Department asking how my 14-day quarantine was going and if I had developed any symptoms. So many thoughts began racing through my mind: Why on earth would they care? Aren’t they busy? Why do they care about people who don’t even have COVID-19? Maybe they are just trying to connect with people? Maybe they are trying to conduct a study on how the COVID-19 pandemic is affecting people? What makes me so special that they are calling me to find out how I am doing?

Eventually, I said, “the shelter-at-home is going okay, I mean, I’m keeping busy since I’m still working”- GASP. The lady on the other line literally gasped.

She stopped me and asked, “Ma’am, you’re… still… working?”.

Well, yeah?

I responded and told her yes, “I work at a coffee shop and I have been working even though we have closed most of our stores”.

Her voice went silent and she eventually said, “Ma’am… you’re supposed to be at home… in quarantine… self-isolating, as you were directly exposed to COVID-19 and potentially have it.”

This was the first time I had been told about the exposure. Apparently, at my last doctors visit, I was directly exposed to a receptionist who later tested positive for COVID-19. I was floored. WHY DIDN’T I KNOW?

On April 2, 2020, I was tested for COVID-19 after explaining to my primary doctor that, although I’m sure it’s just anxiety, I have been experiencing shortness of breath and a heavy chest. She asked how long the symptoms were happening and how often I was experiencing them. I explained to her that I have been experiencing these symptoms for about a week and it was constant. I continued to tell her that I cannot walk around the block without being so short of breath that I am literally gasping for air, but again, it is probably just anxiety. I mean, really, would a healthy 21-year-old female catch the coronavirus? And even so, why would it be the coronavirus when I have so much stress; I just moved all my classes online, I am graduating in less than a month, I can no longer see my boyfriend after he graduates from basic training- there’s really no reason to stress about this being the coronavirus. She believed me as well. She was convinced, just as much as me, that it was probably just anxiety and there was nothing to worry about, but, better safe than sorry.

On April 6, 2020, my results came back. I tested positive for COVID-19.

This isn’t new, there is no secret, there is no surprise; women are treated differently. Women have expectations, mainly dictated by men, to not claim they are hurting, struggling, or sick. When women are actually sick, or hurting, or struggling, they are thought to be just emotional; no matter what it is, it can always be explained by their emotional state. Heart attack? Probably just anxiety or a panic attack. Autoimmune disorder? Just depression. Stroke? It’s anxiety. Their physically sickness rarely exists because it can always be explained by their mental sickness; mental health issues. COVID-19 is no exception.

We have seen it throughout history, from the time Ancient Egypt coined the term “hysteria” claiming that women’s “issues” were all because of their mental health. To Plato claiming the uterus is sad and troubled when it does not join with the male in the act of giving birth. To Aristotle claiming women can be released from their “issues” if only they participate in Maenads, the act of wine and orgies. To Hippocrates using the term hysteria to claim epilepsy was just a woman experiencing mental health issues and their uterus was just restless and poisonous due to a lack of sexual activity with a man. To Sigmund Freud believing women with sickness were just experiencing “penis envy”, the act of being so devastated and disheartened that you do not have a penis that you develop a sickness. To now, where women are still experiencing the belief that their actual, true, physical sickness is just a mental health issue and their body is punishing them for being a woman.

In a time of crisis, we are expected to keep calm, keep our cool. But how can we? How are we supposed to not panic during a time like the COVID-19 pandemic? Why are we expected to believe our symptoms of COVID-19 are just mental health issues? And more importantly, why are our symptoms simply brushed off as mental health issues? This type of mentality is dangerous, especially for women, as it mainly pertains to them. We have created women who are scared to express their symptoms because they will be downplayed to mental health. In a world as uncertain as now, this is the last thing we should be allowing women to do.

When I was experiencing signs of COVID-19 I simply brushed off these symptoms as anxiety; I believed the shortness of breath I was experiencing while walking around the block was simply anxiety and stress. This is the world that has been created for me. We have created a world where women are constantly downplaying their symptoms of real issues because of fear to the point that I was afraid to address real symptoms I was experiencing in fear that I would not be believed. Time and time again, I have seen doctors and physicians who have downplayed my serious medical issues to mental health. For example, when my body was physically rejecting my recently placed IUD, I was told that I simply just had “bad cramps” and they will go away in a few days. They did not. I ended up back in the hospital a few days later being told the same thing. It wasn’t until a doctor took me seriously and realized the “bad period cramps” I was experiencing was actually my body rejecting my IUD. And I am not the only one. Women everywhere have stories of similar experiences; my mother for example. When she was actively having a heart attack, she was told that she was experiencing a panic attack because her symptoms only included nausea.

THIS. NEEDS. TO. CHANGE. We cannot allow women, and men, and anyone else in between, to allow women to brush off their symptoms of serious disorders, especially in a time of the COVID-19 pandemic. As of 2020, women know damn well between the difference of physical health and mental health.

A coda: As of April 21, 2020, I am fully recovered and no more symptoms; no heavy chest, no more shortness of breath, no more anxiety. Although I am fully recovered, my resentment and anger towards the healthcare system still stands. I am still angry at the way I have been treated, and in the way I have allowed myself to be treated, but eventually we will know how to change this, how to do better. Right now, I am currently staying away from work but will continue back after graduation. As of now, as many other members of the class of 2020 in my position, I am in search of a “grown-up” job to jumpstart my career. However, that seems far fetched; in times like now, I am so uncertain that a career-related job is even real, if there’s even a possibility of a job when we are beginning this deep health and economic crisis.

Abby Wikholm is a 21-year old senior at the University of Colorado-Boulder graduating this May 2020. She studies psychology and sociology, with a concentration on criminal justice and mental health. She aims to become a lawyer, to be a voice for the poor, disadvantaged, and disenfranchised. Her training and experience have taught her the prevalence of mental illness and how it affects individuals as well as their families and friends. She just joined twitter, so follow her at @WikholmAbby and support the Class of 2020.

 

This month’s column features our first guest-post from Liz Borkowski, MPH. Liz is the managing editor of Women’s Health Issues and a researcher at the George Washington University Milken Institute School of Public Health. She focuses on reproductive health, paid leave, and US health policy, and is a regular contributor to the public health blog The Pump Handle.

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What’s the best way to help lesbian and bisexual (LB) women lose weight, when their communities may question the very goal of weight loss? That’s a question behind the “Healthy Weight in Lesbian and Bisexual Women: Striving for a Healthy Community” (HWLB) initiative. The answer they came up with was to focus the program on physical activity and nutrition, rather than numbers on a scale. Their findings suggest that this can be an effective approach for helping lesbian and bisexual women adopt healthier habits. Nearly all (95%) of participants achieved one or more of the health objectives, which included nutrition and physical activity goals as well as weight reduction. That included 57% of participants increasing their weekly physical activity minutes by 20% – habits that, if sustained, could contribute to years of improved health.

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The Women’s Health Issues supplement about the study contains lessons for healthcare providers who serve lesbian and bisexual women. As Natalie Ingraham and her colleagues explain in an article about provider interventions, lesbian and bisexual women may not disclose their sexuality to providers who seem to presume heterosexuality; lack of disclosure can lead to inadequate care. Weight bias can also be common among healthcare providers:

“…stigma and discrimination related to sexual orientation and gender identity may be compounded by stigma related to weight and body size.”

To address this, the researchers developed and evaluated two curricula for providers to enhance their ability to provide high-quality care to LB “women of size” (overweight or obese). Focus group participants explained that they wanted providers’ help in overcoming barriers to healthy habits, not providers making them feel shamed or blamed for their weight. Based on this feedback and prior studies, the team developed two curricula that involved cultural competency training and motivational interviewing (MI) techniques:

“Rather than trying to convince clients to change, providers trained in MI elicit arguments for change from the clients themselves…These techniques help clients to explore and resolve ambivalence, develop self-efficacy, and set personal goals.”

The team pilot tested the “academic format” training with physicians, residents, and medical students at universities in Washington, DC and Nashville, Tennessee. They pilot tested the “clinic format” training with staff and providers at Lyon-Martin Health Services, a Program of HealthRight360, which provides care to LGBT clients in the San Francisco Bay Area. Ninety-six participants completed tests before and after the trainings; results showed the most change on questions about patient-provider interactions and LB women’s avoidance of care.

Specifically, after the trainings, more participants (correctly) agreed with the statements “Lesbians and bisexual women may avoid health care because they don’t trust the practitioner to be culturally competent” and “Overweight and obese women often delay or avoid health care if they feel their health care provider holds a bias against women who are large.” More participants also (correctly) disagreed with the statement “Physicians/nurses should always instruct their overweight/obese patients to lose weight.” There was also more (correct) agreement with this statement, which encapsulates what providers can do to help overweight clients:

“Patients who are advised by their physician how to modify their behavior to lose weight are more likely to lose weight than those who do not get this advice.”

While the authors of this article note the need for additional research on these curricula – including studies to see whether they improve clinical practice – their findings, combined with the findings of the overall HWLB study, have some clear implications. Instead of instructing all overweight or obese lesbian and bisexual patients to lose weight, providers should offer advice on adopting healthier behaviors. It is key that this advice be presented in ways that don’t contribute to stigma on the basis of larger size or sexual orientation.  To better serve lesbian and bisexual patients, health care providers should familiarize themselves with cultural norms and problematic stigmas that LB women may face. Then, during patient interactions they should make sure to sensitively include “open and positive acknowledgement of sexual orientation.”

OctGwP
Photo Credit: Jennifer Rothchild

This month, I bring you a guest post which sheds light on current events, events that literally hit home for me when the Planned Parenthood clinic closest to my university was attacked by arsonists. I welcome back Jennifer Rothchild, Ph.D. Associate professor of Sociology and Coordinator of the Gender, Women, & Sexuality Studies (GWSS) Program at the University of Minnesota, Morris, she is one of the founders of the American Sociological Association’s section on the Sociology of Development. She currently researches gender and development, health, childhoods, and social inequalities by examining the intersections of gender, sexuality, and reproductive health in the United States and abroad.

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“Choose mercy! While there is still time!” A man shouted to me as I walked into a Planned Parenthood office. I couldn’t see him, which made the comment oddly affecting. I kept my eyes forward and pushed through the front door.

More than 20 years ago, my friend Kat had told me about her first trip to Planned Parenthood. As she left that building, a woman standing outside approached her, grabbed her shoulders, and cried, “‘DO YOU KNOW WHAT YOU HAVE JUST DONE? DO YOU KNOW WHAT YOU HAVE DONE?’”

I will turn 45 this February, and yesterday was my first visit to Planned Parenthood. Shame on me: a self-proclaimed activist, and a gender and sexuality scholar. Until now, my privilege had allowed me to get all the women’s health care I needed through medical clinics and private practice physicians. All covered by insurance. But I knew Planned Parenthood was always there, should I ever need their services.

I had a health problem, and this time I chose Planned Parenthood because that is what it is: a health clinic. The woman at Planned Parenthood who booked my appointment warned me: “You should know that this clinic will have protesters. Turn into the parking lot, and a volunteer will help you get by the protesters, and then park.”

There are many misconceptions about Planned Parenthood; here are some facts:

  • Planned Parenthood services include STD/STI (sexually transmitted disease/sexually transmitted infection) testing and treatment for both men and women, cancer screenings, contraception, abortions, and other health services.
  • Abortions make up less than 3% of the services provided by Planned Parenthood.
  • Federal funding for Planned Parenthood is only for Title X: restricted to family planning and STI testing.
  • Planned Parenthood clinics that provide abortion services do not receive any federal funding, even if those particular clinics also provide services that meet Title X criteria.

On a rainy, cold morning, I arrived at Planned Parenthood, and a volunteer waved me into the parking lot. Next to this volunteer stood a protester, holding a sign about texting a certain number before “aborting.” I wondered if these two women talked to each other as they stood together in the rain?

Once inside, I was overwhelmed by a need to express gratitude to everyone I met. I assumed that most Planned Parenthood patients felt same way, if not always vocalizing their sentiments. But I was wrong. My intake nurse told me that just that morning a patient told her, “I hate who you are. I hate what you do. I don’t want to be here, but I need birth control pills.”

Her story made me wonder about the level of denial and disconnect that must be actively maintained to keep those ideas working side by side. In 2012, Frank Bruni wrote in the New York Times about a doctor who performed abortions:

He shared a story about one of the loudest abortion foes he ever encountered, a woman who stood year in and year out on a ladder, so that her head would be above other protesters’ as she shouted ‘murderer’ at him and other doctors and ‘whore’ at every woman who walked into the clinic.

One day she was missing. ‘I thought, ‘I hope she’s O.K.,’ he recalled. He walked into an examining room to find her there. She needed an abortion and had come to him because, she explained, he was a familiar face. After the procedure, she assured him she wasn’t like all those other women: loose, unprincipled.

She told him: ‘I don’t have the money for a baby right now. And my relationship isn’t where it should be.’

‘Nothing like life,’ he responded, ‘to teach you a little more.’

A week later, she was back on her ladder.

That morning, security was at a premium at the Planned Parenthood clinic: a guard stood at the front door, and I needed to show him identification. I was given a name tag that read only “Jennifer.” A few minutes later, “Jennifer R.” was summoned from the waiting room. I wondered how much money could be saved and put to better use if Planned Parenthood didn’t feel compelled by threats and attacks to spend on security measures.

In the waiting room I saw young and old women, white and black and Latina. There were men, too. I couldn’t imagine the individual stories that brought them to Planned Parenthood. But, I might have assumed they all shared was a lack of access and means to the kind of health care that should be their right. According to a 2012 report from the Government Accountability Office, 79% of people receiving services from Planned Parenthood lived at 150% of the federal poverty level or lower (that comes out to around $18,500 per year for a single adult). These people live in vulnerable conditions, where an unplanned pregnancy could result in future burdens, unfair and disproportionate in consequence.

If Planned Parenthood clinics are shut down, we will see not only tremendously diminished reproductive health but also epidemic numbers of unplanned pregnancies and unsafe abortions, as well as greater needs for social services such as WIC. Concerns for women’s health aside, Planned Parenthood delivers mercy upon people who benefit from its services.

The nurse practitioner spent time talking with me, getting to know me. I told her how grateful I was for the work she did. She graciously explained, “I started working here 15 years ago to educate women about their bodies. Women don’t know their bodies.”

Driving out of the parking lot, I stopped and rolled down my window to thank the same volunteer who had stood in the rain when I arrived, waving me into the parking lot. There was now a different protester. This woman was young, white, blonde, and wearing a pink raincoat. She could have been a twenty-something version of me. In her hand, she clutched a brochure limp from the rain. Her sad gaze followed me as I drove away. I wish she saw and knew the things I understood.

I also wish everyone understood that Planned Parenthood volunteers, nurses, and doctors risk their own safety and well-being because women’s health—and women’s lives—hang in the balance. These women and men are standing up and fighting for me, fighting for you.

“Choose mercy.” Yes, we should.

 August already? The summer has sped by. Each time a new atrocity hits the airwaves—anti-voting legislation, another police shooting of an unarmed black citizen, new measures to curtail access to women’s reproductive health care—I pause. What can I possibly say that hasn’t already been said by others as sick at heart as I am? So many eloquent voices have been raised and yet new assaults on citizens’ rights continue.

Ninety-five years ago this month women won the right to vote. Fifty years ago, August 6, 1965, Congress passed the Voting Rights Act . Those of us who witnessed the passage of the 1965 legislation hoped that finally we had a way to overcome many of the barriers racism had built. Racism remained virulent, as the Watts riots—the very same August of 1965—revealed. But with more equal voting rights, I along with many others, hoped further progress could be made. Often people speak as if the 19th amendment was ‘for women’ and the Voting Rights Act was for ‘minorities’ as if Black and Hispanic women aren’t hampered by racism every bit as much as they are by sexism.

And during the last fifty years we made progress on a second critical aspect of the struggle for women’s equality—the right to control our own bodies. Without access and choice in matters of birth control and reproductive health, even the right to vote leaves women caught in a world where biology too often equals destiny. The birth control pill was a major breakthrough—by the mid 1960s more than five million American women were using ‘the Pill’. And by 1972 the Supreme Court had overturned state laws prohibiting the use of contraceptives by unmarried people . The 1973 Court decision in Roe v Wade protected a woman’s right to terminate a pregnancy at any point during the first 20 weeks.

But the path forward for women’s equality and reproductive rights soon twisted. Opposition to the Equal Rights Amendment (ERA) which had seemed headed for passage in the 1970s, stalled and although the deadline for ratification by the required thirty-eight states was extended to from 1979 to 1982, the Constitutional amendment failed.

Today’s reality is shaped by decades of work by anti choice activists with little concern for the health and self-determination of women. They have campaigned relentlessly to overturn Roe v. Wade. They threaten abortion providers; even murder staff and doctors. And they spread all manner of false information on the ‘terrible consequences’ and ‘life long regrets’ of abortion procedures. All this goes along with strengthened opposition to sensible sex education.

Today women, especially poor women without the financial resources to travel and to pay for medical advice and assistance, are no longer able to count on controlling our own bodies. Under the guise of saving unborn babies, and ‘protecting’ the health of women, conservative legislators are proposing and passing wildly expanded restrictions on access to sound reproductive health care. Programs such as Colorado’s that clearly lower rates for teen pregnancy and abortion by providing access to effective birth control are denied public funds. Using misleading data and heavily edited videos they demand the defunding of Planned Parenthood and the critical health services the organization provides.

It is no coincidence that these campaigns often go along with opposition to equal pay legislation and increases in the minimum wage, opposition that keeps the poor, poor. Meanwhile, the conservative agenda has muted potential pro-choice advocates. Many choose to ignore the threats to women’s rights, convincing themselves that they are not personally affected.

Reproductive rights can never be separated from the struggle for women’s equality. They are a central component. So let’s get busy and understand what’s at stake. In a recent New York Times opinion piece Katha Pollitt said it best:

“[The stakes are] about whether Americans will let anti-abortion extremists control the discourse…Silence, fear, shame, stigma. That’s what they’re counting on. Will enough of us come forward to win back the ground we’ve been losing?”

I hope so. I am not the only woman who helped friends when they needed an abortion. I am not the only parent whose developmentally challenged daughter would require an abortion if she were to become pregnant. I am far from alone in my outrage and disgust with the current climate, and I am certainly not the only one speaking out.

But there are more women and men still to be heard from. The stakes are high. We need every voice, every personal story that can deepen understanding of the costs to women, their children and families that result when reproductive freedom is curtailed. Impersonal facts alone carry so little of the truth that matters, the truths that touch and sometimes change hearts and minds.   Now is the time to speak up—in public as well as private conversations; to write heartfelt letters; to send a larger-than-usual donation to organizations battling for reproductive rights. Action is required—and it is required now.

Tina Pittman Wagers is a clinical psychologist and teaches psychology at University of Colorado Boulder. She just survived a heart attack.

Tina Pittman Wagers finished a triathlon six weeks ago.
Tina Pittman Wagers finished a triathlon seven weeks ago.

I am new to this role as a heart patient. My heart attack was five weeks ago, and I am getting the feeling that I have just begun down the confusing maze of angiograms, CT scans, EKGs, medications (and lots of ’em), heart rate monitors, cardiac rehab classes and blood tests. Indeed, even the phrase “my cardiologist” is one I never thought would pass my lips. Here’s why: I am 53 (we’ll discuss the significance of this age in a moment). I am fit, active, slim, haven’t eaten red meat for about 20 years and am a big fan of kale, salmon and quinoa, much to the chagrin of my two teenage sons. I live near the foothills in Boulder, Colorado, where I hike with my dog and often a friend or two, almost every day. I had completed a sprint triathlon two weeks before my heart attack. Ironically, this event was a fundraiser for women with breast cancer – it turns out that heart disease kills women with more frequency than breast cancer. But, hey, who knew?

My heart attack happened while I was swimming across a lake in Cascade, Idaho. I was about a quarter mile into the swim when I found that I couldn’t breathe, and was grabbed by an oddly cold and simultaneously searing band of pain about three inches wide across my sternum. My husband, Ken, was on a paddleboard nearby and helped pull me out of the water, and started paddling me back, stopping to allow me to vomit on the way back to shore. If you’ve never been on a paddleboard, it may be hard to imagine the balance it takes to paddle relatively quickly and keep the board from getting tipped over by the unpredictable movements of a heaving passenger in the midst of a heart attack. Suffice to say that I am grateful for Ken’s strength and balance in innumerable ways. An hour later, I was at a clinic in McCall, Idaho, where an astute ER doc was measuring my heart rate (very low) and heart attack-indicative enzyme called Triponin (rising) so I won an ambulance ride to St. Luke’s Hospital in Boise, Idaho. I received excellent care there, queued up for an angiogram the next morning and was diagnosed with SCAD: a spontaneous coronary artery dissection, and, fortunately, a relatively mild one. Twenty percent of SCADs are fatal. Furthermore, I have none of the typical risk factors for heart disease, like high blood pressure, diabetes or high cholesterol.

I do have one of the main risk factors for this kind of heart attack, though: I am a woman. Eighty percent of these heart attacks occur in women. The average SCAD patient is 42, female and is without other typical risk factors for heart attacks. The current thinking about SCADs is that they are not as rare as originally thought, but are under- diagnosed because they happen in women who don’t look like typical heart patients.

Another related factor: I am menopausal. The majority of SCAD patients are post-partum, close to their menstrual cycle or menopausal – all times in women’s lives during which we experience significant fluctuations of sex hormones. Up until five days before my heart attack, I had been on low doses of Hormone Replacement Therapy (HRT), in an effort to vanquish the hot flashes, sleep disruption and cognitive fogginess I was experiencing. I suppose HRT might have also represented an attempt to hang on to youth, in a youth-and sexuality-obsessed culture in which the transition to menopause often means a dysregulated and sweaty march into irrelevance.

Since I had my heart attack, I’ve spent a lot of time (and money, but that’s another column) interacting with professionals in the cardiology world, trying to figure out what happened to me, and how I can avoid having another SCAD – the rate of recurrence in my population is about 20-50 percent. I have encountered some lovely people, but almost all of them are baffled about what to do with me. I am atypical, as they inevitably explain, but the medications, the treatments, the rehab programs that they have to offer are designed for typical patients. So, that’s what my doctors try, but there is a lot of “voodoo vs. science” as one cardiologist explained, because science doesn’t have the answers to my questions. (I would add that there is a cardiologist, Dr. Sharonne Hayes at The Mayo Clinic, who is doing a lot of the research and seeing the patients who’ve had SCADs. I hope to meet her one day. I imagine a scene something like my 13-year-old self meeting David Cassidy, only in an exam room in Rochester, Minnesota– it’ll be just that cool.)

One of the factors that contributed heavily to my medical predicament was no doubt my menopausal and HRT status. The American Heart Association points out that lower estrogen levels in post-menopausal women contributes to less flexible arterial walls, clearly a factor in SCADs. The question then arises: how might HRT help prevent another heart attack? However, as anyone who’s even scratched the surface of the HRT world, there is a lot of conflicting data about who should use HRT, who shouldn’t, what the benefits and risks are, and what the differences may be between different formulations and methods of delivery of HRT. One study, the Women’s Health Initiative study, was a large study started in the early 1990s, and was a valiant attempt to gather data about the effects of HRT on women’s health, including cardiovascular health. Unfortunately, the average age of the women in this study was 63 – 12 years older than the typical age of the American woman hitting menopause and considering HRT, so the results have been criticized for their poor generalizability to newly menopausal women.  The research on HRT since the WHI study has been scattered, often contradictory, and hard for the average woman to access.

Why do we know so little about women and heart attacks, why they happen, what the symptoms are, and what we can do about hormonal factors that contribute? A big part of the problem is that, until the National Institute of Health (NIH) Revitalization Act in 1993, researchers largely excluded female humans from their studies. NIH has just this year (2014!) decided to use a balance of male and female cells and animals in their research. Up until now, 90 percent of the animal research has been conducted on males. Animal research, which is often a precursor to clinical trials in humans, has been missing out on vast pieces of investigation related to the female body. I am living (fortunately) proof of the fact that the delays in including females in research have translated into significant gaps in clinically relevant knowledge related to women’s health. Well-meaning physicians and practitioners only have the “typical” approaches to try with their “atypical” patients. Why this appalling delay to include female subjects? Because female rodents as well as humans experience menstruation and menopause, which are frequently considered dysregulating nuisances to many scientists. As a consequence, we have an enormous amount of catching up to do in order to understand what factors affect female bodies and health problems in different ways than our male peers.

Emma Watson gave a great talk last week to the UN about feminism meaning equal access to resources. One of the most important resources we have is scientific knowledge that can be applied to responsible, effective and efficient clinical care. Let’s hope that women can start to be understood as typical research subjects and patients, not as inconvenient, fluctuating, atypical anomalies.

Abigail_AdamsToday is the 4th of July, Independence Day. “We hold these truths to be self evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness.“

These stirring words, drafted in June 1776 by Thomas Jefferson, the principal writer of a committee of five— John Adams, Benjamin Franklin, Robert Livingston and Roger Sherman were the others—have inspired Americans for more than 200 years. Most people today assume the term ’men’ means all citizens. “Most” apparently doesn’t include five of the male members of the U.S. Supreme Court. Their June 30th majority opinion gave many  U. S. companies the right to dictate, based on the religious beliefs of their owners, the types of contraceptive coverage female employees can access under their health insurance.  The dissenting minority included the three female members of the court as well as Justice Stephen Bryer. Justice Ruth Bader Ginsburg wrote a forceful, thirty five-page dissent calling the decision one “of startling breadth”. As Virginia Rutter wrote here at Girl W/Pen, June 30th was “a terrible, horrible, lousy day.”

Things haven’t gotten any better. Yesterday Justice Sonia Sotomayor wrote a blistering dissent to the Court’s temporary order allowing Wheaton College a religious exemption to filing a required form under the Affordable Care Act.  Women, who understand the role of reproductive rights, including the right to use the method of contraception they and their physicians consider best for them as individuals, see through the careless reasoning of the five conservative male members of the Court. Justices Elena Kagan and Ruth Bader Ginsburg joined Justice Sotomayor who wrote that the order was at odds with the June 30th Hobby Lobby decision. “Those who are bound by our decisions usually believe they can take us at our word. Not so today. After expressly relying on the availability of the religious-nonprofit accommodation, ….the Court now, as the dissent in Hobby Lobby feared it might, retreats from that position.”

Clearly if women thought we had gained full equality, the Supreme Court decisions of the last few days have put that fantasy to rest.

Political historians have long pointed out that the terms ‘man’ and ‘citizen’ were often considered synonymous, meaning, in fact, only men and only certain men. In the newly formed United States, women were citizens, but citizens who could not vote and whose first loyalties were not to the nation or the community, but to their husbands and fathers. Abigail Adams’ plea to her husband John in March 1776 as he worked to shape the new government, “…remember the ladies, and be more generous and favorable to them than your ancestors. Do not put such unlimited power into the hands of Husbands. Remember all Men would be tyrants if they could” fell on deaf ears . Historian Linda Kerber has pointed out that the “revolutionary generation of men who so radically transgressed inherited understandings of the relationship between kings and men, fathers and sons, nevertheless refused to revise inherited understandings of the relationship between men and women, husbands and wives, mothers and children. They continued to assert patriarchal privilege as heads of households and as civic actors” (Kerber, 1998, No Constitutional right to be Ladies).

Women eventually organized, just as Abigail Adams had warned her husband. “If particular care and attention is not paid to the Ladies we are determined to foment a Rebellion, and will not hold ourselves bound by any Laws in which we have not voice, or Representation.” It took another 140 years before the 19th Amendment guaranteed women’s right to vote in 1920; but the women and men who fought for women’s suffrage eventually won the battle. In 1923 Alice Paul, a leader of the suffrage movement, drafted the Equal Rights Amendment.  She saw the ERA as another step necessary to assure equal justice under the law for all citizens. The wording is brief, clear: “Equality of Rights under the law shall not be denied or abridged by the United States or by any state on account of sex.”

In 1876, referring to the U. S. Constitution, signed only a few months after the July 4th Declaration, Susan B. Anthony noted “It was we, the people; not we, the white male citizens; nor yet, we, the male citizens; but we, the whole people, who formed the Union.”

It’s an old feminist adage that ‘feminism is the radical notion that women are people.’ (see here and here)  Fighting for the passage of the ERA, ratified by only 35 of the 38 states needed before the 1982 deadline imposed by Congress, may seem far too quixotic an undertaking in the current political climate. But let’s remember the long battles for the right to vote, the continuing struggle for racial equality, the ongoing battle for equal rights for members of the LGBT community. The struggle for human rights and dignity takes lifetimes, set backs hit hard. But human rights are truly lost only when we give up, give in, surrender.

Sometimes I’m tempted. But not today, not on the 4th of July, not with Abigail Adams and those who followed in her footsteps to inspire us.

 

Looking ahead to Mother’s Day and Father’s Day, I encourage readers to check out Chloe Bird‘s latest post for The RAND Blog. In “Assessing and Addressing Women’s Health and Health Care,” Bird explains the knowledge gaps and emphasizes the benefits of changing our approach to health research:

Gender-stratified research can produce more effective decision tools and interventions, and in turn improve both women’s and men’s health and health care.

I have featured her work on women’s cardiovascular health in a past post: it’s an excellent example of why we need to pay attention to sex/gender differences when aiming to improve health care.  Bird cautions of the dangers of failing to make the necessary revisions:

Until access, quality, and outcomes of care are tracked by gender, inequity in treatment will remain invisible and consequently intractable.

As we move forward with the Affordable Care Act, it is important to pay attention to the new assessments and tracking of the quality of care.  In the words of Bird, “This tracking should take gender into account so that disparities in health care and outcomes become visible and get the attention they deserve.”

 

Valentine’s Day is not the only reason to think about hearts in February, a.k.a. American Heart Month.  This guest-post on women’s heart health by Chloe E. Bird, Ph.D. — senior sociologist at the nonprofit, nonpartisan RAND Corporation and professor at the Pardee RAND Graduate School — discusses findings from a recent RAND pilot study.*  In our email exchange, Chloe emphasized, “…please don’t assume that you, or the women in your life, are too young to be concerned.”

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High-quality routine care for both cardiovascular disease (CVD) and diabetes is at least as relevant to women’s health and survival as it is to men’s.  Yet evidence suggests that women continue to face gaps in even low-cost, routine aspects of care.

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CVD is the leading cause of death for women, as well as for men. More than one in three adult women has some form of CVD.  In fact, since 1984, more U.S. women than men have died of CVD, and 26 percent of women over age 45 die within a year of having a recognized heart attack, compared with 19 percent of men. Diabetes is a major cardiovascular risk factor, and it increases risk of CVD more so in women than in men.

Despite improvements over recent decades in care for CVD and diabetes, evidence suggests that the care women receive—and their health outcomes—continue to lag behind those of men, even for routine care such as monitoring and control of cholesterol. Although the American Heart Association’s “Go Red for Women” campaign and efforts by Sister-to-Sister and WomenHeart have done much to raise awareness among both women and their clinicians about CVD, there is still too little attention devoted to preventing heart disease in women.

Part of the problem is that quality of care is not routinely measured and reported by gender. Conventional methods of measuring quality of care focus on average “quality performance scores” across the overall population. Separate assessments and reporting by gender are rare, so the care received by women is generally assumed to be equal to that received by men, despite evidence to the contrary. As a result, the quality gap in care remains largely invisible to individual women, providers, payers and policymakers, even among those seeking to improve women’s health and health care. In cases where gender gaps in care have been monitored and targeted, such as in recent initiatives by the Veterans Health Administration, marked reductions in gender disparities in CVD and other types of care have been achieved; though some gaps persist.

In an examination of gender gaps in cholesterol screening among adults in one large California health plan who had been diagnosed with CVD or with diabetes, we found larger gender differences on average in care for CVD (5 percentage points) than for diabetes (2 percentage points). Although the gaps may appear small among the 30,000 CVD patients and 155,000 diabetes patients whose care we examined, they translate into a significant number of women who were not screened, but who might have been had they been men.

We focused on screening because clinicians agree that CVD and diabetes patients should receive annual screenings for high LDL cholesterol.  Such screening is also the first step in assessing quality of care.  Moreover, research on disparities in care often finds that gaps in screening are associated with larger gaps in treatment and poorer intermediate outcomes.

In our study, gender gaps in cholesterol screening varied geographically and favored men far more often than women. Among CVD patients, there were gaps favoring men in 79 percent of counties. In 35 percent of counties, those gaps were moderate (from 5 to less than 10 percentage points) or large (at least 10 percentage points). In 12 percent of the counties there were small gaps (from 1 to less than 5 percentage points) favoring women. Among patients with diabetes, which has not traditionally been viewed as a man’s disease, there were moderate gaps favoring men in 17 percent of counties and small gaps favoring men in another 40 percent of counties. In contrast, there were large gaps favoring women in 4 percent of counties, moderate gaps in 2 percent, and small gaps in another 12 percent.

Lessons from areas with the highest quality of care and from areas with the fewest gender disparities can motivate efforts to improve care and reduce disparities. Mapping quality of care at specific geographic levels and focusing on the areas of interest to specific stakeholders may prove to be essential to efforts to tackle disparities efficiently and meaningfully.

Without gender-stratified reporting of quality of care, gender gaps are invisible and intractable. Such reporting is essential if health plans, health care organizations, and policymakers are to ensure that overall improvements in care narrow gender gaps.

Health plans should use gender-based analysis and mapping to address gender gaps and to motivate improvements in care, treatment and outcome measures. Similarly, analyses of pooled data from multiple health plans could be used to assess gender disparities in care for CVD and diabetes for managed care patients and determine whether the size and patterns of disparities differ across plans.

Closing the gender gap is crucial if women are to benefit equally from improvements in care for CVD and diabetes.  At the same time, focusing on gender gaps can inform a broader discussion of the prevalence and burden of CVD in women and the need for improvements in prevention, diagnosis and treatment.

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*For more information, check out the online report and videos of her presentation and other researchers’ talks from RAND and UCLA’s recent women’s heart health event.

In the wake of Angelina Jolie’s NYT op-ed about undergoing a preventive double mastectomy, many experts have weighed in — to critique, to analyze and to correct misconceptions.  I’m keeping this month’s column short to encourage readers to explore some well-researched analyses.  I’m particularly inspired by a past guest-author for this column, Gayle Sulik, Ph.D. (author of Pink Ribbon Blues and Research Associate, Department of Women’s Studies, University at Albany – State University of New York).  Sulik’s guest post for Scientific American is a must-read for those who have questions and concerns about what Jolie’s story may or may not mean for themselves and their loved ones.  If you prefer a podcast, then listen to KCRW’s interview with a panel of experts, including Dr. Sulik along with Alice Park (author of The Stem Cell Hope and health reporter for Time magazine), Joanna Rudnick (BRCA activist and documentary filmmaker), and Ellen Matloff, M.S., C.G.C. (Director of Cancer Genetic Counseling at Yale Cancer Center).

I leave you with this quote from Sulik:

…we all deserve quality information, evidence-based medicine, and access to comprehensive and coordinated health care that is free from conflicts of interest and the profit motives of commercial enterprises that are eager take advantage of our fears while selling us superficial “solutions” to our problems.

This month’s column features one of our past guest authors: Chloe E. Bird, Ph.D. is a senior sociologist at the nonprofit, nonpartisan RAND Corporation and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press).

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In the past two months, two of my friends–both seemingly healthy women–became unlikely victims of cardiovascular disease. One, a woman who by any textbook definition would be considered at low risk for heart problems, nonetheless suffered a heart attack. Thankfully, she is recovering. The other, a longtime friend and a mentor of mine, tragically passed away after suffering a stroke. These experiences left me wondering how we can accelerate efforts to reduce cardiovascular disease risk and mortality in women.

As a women’s health researcher, I am concerned about how long it is taking to bring attention and resources to this problem. After all, it has been decades since we’ve learned that cardiovascular disease affects women every bit as much–or even more–than it does men. Indeed, since 1984, cardiovascular disease has killed more women than men in the United States. When it comes to women’s health, cancer gets a good deal of the attention; somehow, it hasn’t fully registered that so many of our mothers, sisters, friends and daughters are being affected by another, often silent killer.

Commonly referred to as heart disease, cardiovascular disease includes both heart disease and other vascular diseases. When tallied separately, stroke is the third leading cause of death among women. Both strokes and cardiac events are all too common in women over 40 and, sadly, so are deaths.

Consider a few statistics:

  • In the U.S., women account for 60 percent of stroke deaths, and 55,000 more women than men suffer a stroke each year.
  • Worldwide, heart disease and stroke kill 8.6 million women annually–accounting for one in three deaths among women.
  • Whereas one in seven women develops breast cancer, more than one in three women has some form of cardiovascular disease.

Although the American Heart Association’s Go Red for Women campaign has done much to raise awareness, there is still too little attention devoted to preventing heart disease in women and improving the quality and outcomes of their care.

While we should celebrate the significant improvements in the care and survival of men with cardiovascular disease, those gains began decades ago, and the death rate among men has fallen more quickly than it has for women. Unfortunately, women continue to face lower rates of diagnosis, treatment and survival. The new Million Hearts campaign aimed at preventing a million heart attacks and strokes by 2017 has partnered with WomenHeart, a national coalition for women with heart disease. This effort is essential and represents progress, but prevention is not the only challenge.

Why are outcomes worse for women? Even if biomedical research on cardiovascular disease had not traditionally focused almost exclusively on men, these conditions would likely still be harder to recognize and treat in women. Women don’t tend to have the “TV heart attack”–the familiar image of a man clutching his left arm or his chest in pain. Rather, for women, the symptoms of a heart attack are often more subtle and less specific. Women can present with symptoms like throat pain or a sore back. In fact, 64 percent of women who die suddenly from heart disease had no previous symptoms at all.

Furthermore, tests that are mostly reliable in assessing men’s cardiac risk are not as accurate in women, largely because they are aimed at identifying major coronary artery blockage. At least half of heart attacks in women are caused by coronary microvascular disease, which involves narrowing or damage to smaller arteries in the heart. This not only makes the diagnosis challenging, but it poses problems for treatment as well. Women often go undiagnosed or incorrectly untreated after major blockages have been ruled out, and optimal treatment of microvascular disease remains unclear. Consequently, 26 percent of women over age 45 will die within a year of having a heart attack, compared with 19 percent of men. The deficits in women’s cardiovascular care may have developed unintentionally, but our efforts to address them need to be both intentional and focused.

Fortunately, we know what it will take to close the gap and get women better diagnosis and treatment for cardiovascular disease. We can start by looking to the fight against breast cancer. Our first task is to call for increased public and private funding for public-health, biomedical and health-services research to reduce women’s risk and improve their outcomes. Second, on the private side, there are many foundations dedicated to addressing cardiovascular risk in women. But they and the women they serve would benefit from more collaboration and better coordination of effort. Finally, doctors and medical clinics need to do more to improve assessment and the quality of women’s cardiovascular care. Otherwise, women’s care and outcomes will continue to lag behind men’s.

Our bodies are complex systems. So, if we want to take on women’s health in a way that truly moves the needle on outcomes, we need a comprehensive approach. Women’s health care in general needs to become a primary focus for research and practice. And improving women’s health and longevity will require us to expand our focus beyond sex-specific reproductive cancers and predominantly female diseases, such as breast cancer. This doesn’t mean that we should divert resources from other areas of study, of course. But we need to recognize that woman-specific health care should not be confined to conditions that don’t (or don’t often) affect men.

The stakes for women are high, but we can and must bring greater attention to women’s cardiovascular health. Personally, I am not willing to let go of another friend, colleague or relative to a condition that could have been caught and treated if women routinely received appropriate preventive care, diagnostic testing and treatment.  It’s time for feminists to take on heart disease as a women’s issue.

— Crossposted with permission from the Ms. Blog