1. Gender Equity in Medicine Terri L. Paul MD FRCPC Cert Endo Associate Dean Learner Equity & Wellness

2. Objectives After this presentation you will be able to: Define Equity Define Gender Equity Define Gender Equality Discuss how to approach equity issues

3. What is the difference between sex and gender? Sex = male and female Gender = masculine and feminine Sex refers to biological differences; chromosomes, hormonal profiles, internal and external sex organs. Gender describes the characteristics that a society or culture delineates as masculine or feminine.

5. Sex vs Gender So while your sex as male or female is a biological fact that is the same in any culture, what that sex means in terms of your gender role as a ‘man’ or a ‘woman’ in society can be quite different cross culturally. These ‘roles’ have an impact on the health of the individual.

6. Examples of sex difference on average female brains exhibit greater ‘plasticity’, male brains are larger and have more neurons males experience an increase in blood pressure in response to pain, females, an increase in heart rate, but blood pressure remains stable, or may even fall high blood pressure in males increases the size of the left ventricle, in females the chamber does not enlarge, but the muscle of the chamber wall thickens

7. Examples of gender differences men develop melanoma more commonly on the back and shoulders, women more commonly on the lower leg high rates of accident and injury, including suicide, occur in men, women suffer more depression globally women use 2/3 of health services, men use health services at a much lower rate

8. Some Commonly Misunderstood Facts ‘gender’ does not mean sex, female or feminism everyone has gender (MEN HAVE GENDER TOO!!!!) everyone’s sex and gender has an impact on their health ‘a gender perspective in medicine’ is not a euphemism for women’s health, feminism or for men needing to ‘get in touch with their feminine side’ misuse of terms is widespread (WHO and UN definitions are the accepted standard)

9. Gender perspective in medicine? We have all been taught that medical knowledge and practice is gender neutral and we apply that knowledge and practice to men and women. As a result we currently teach that medicine is gender neutral

10. Is It Gender Neutral? The gendered nature of medicine has significant clinical consequences for patients. For example: Women < 50 years old have 24% higher mortality rate from myocardial infarct than men of the same age We are taught and still teach that some of the major symptoms experienced by patients suffering acute myocardial infarct (AMI) are: – crushing chest pain – pain radiating into the left arm – feeling of acute indigestion

11. Symptoms of an acute myocardial infarct the reality is that these are the symptoms most commonly experienced by male patients suffering AMI. Recent evidence has demonstrated that most female patients don’t report experiencing the crushing, vice-like chest pain radiating to the left arm; the symptoms they report are quite different.

12. Female Symptoms of AMI shortness of breath – 58% weakness – 55% unusual fatigue - 43% cold sweat – 39% dizziness – 39% J American College of Surgeons, 2004; 198: 177

13. Feb 9, 2014

14. 60 Minutes Have practitioners been treating male and female patients the same when they shouldn't? Or, have they come up with their own methods for addressing physiological differences between the genders?

15. This recent '60 Minutes' review of gender differences in prescribing practices highlights known medical information on these differences in heart attacks, aspirin, and Ambien [zolpidem] It has been understood for quite some time that men and women may have differing reactions to medications, at least anecdotally based on the types of complaints we get when a medication causes a side effect.

16. In the past, most of the large trials were done on white male patients. We know that gender, race, and age can be a factor when considering medication dosages, medication response, and also disease processes. The problem is that we do not know all of the differences yet

17. What Does Gender Equity Mean?

18. Equity eq·ui·ty Noun/ˈekwitē/ The quality of being fair and impartial: "equity of treatment". The state, quality, or ideal of being just, impartial, and fair.

19. Gender Equity Gender equality (also known as gender equity, gender egalitarianism, or sexual equality) is the goal of the equality of the genders or the sexes, stemming from a belief in the injustice of myriad forms of gender inequality. en.wikipedia.org/wiki/Gender_equity en.wikipedia.org/wiki/Gender_equity The application of fairness or justice in all gender issues. This applies both to the composition of power structures and to social divisions of labor. www.ippfwhr.org/en/en/resources/glossary www.ippfwhr.org/en/en/resources/glossary

20. Interpretation in Important

21. Gender Equity means fairness and justice in the distribution of benefits and responsibilities between women and men.... genderandhealth.ca/en/modules/introduction/introduction- glossa genderandhealth.ca/en/modules/introduction/introduction- glossa though often used interchangeably with gender equality, is a very distinct concept. Equity programs favor treating women and men differently in order to achieve the equal status of women and men.... www.expeditingtheinevitable.com/resources/glossary/ www.expeditingtheinevitable.com/resources/glossary/

22. Case You are on call for your Ob/Gyn rotation One of the patients you have been following in clinic with Dr Rebel is admitted in active labour As you go to enter her room to evaluate her, you are stopped by the labour and delivery nurse who says “ As a rule, I won’t have a male in this room”

23. Case Questions How do you feel? What would you do? Is this response adequate?

24. Case You signed up for a marginalized communities elective at the London Middlesex Health unit Involves work at an addictions center, a refugee health clinic and the high risk birth control unit When you receive your schedule, you notice your female classmates have 3 full days at the birth control clinic You have none

25. Case You call the rotation leader and ask what is happening The only answer is that they advertize the clinic as a female physician only clinic “Enjoy your 3 days off”

26. Case Questions How do you feel? What would you do? Is this response adequate?

27. Who has the ultimate decision as to whether a student should be involved in the care of a specific patient? That decision lies with the patient and should not be made for the patient by physicians or allied health care professionals without consulting the patient

28. What Does Gender Equity in Medical Education Mean? Equal opportunity without regard to gender May not be equivalent or identical but should provide equal experience Exclusion from certain learning experiences based on gender is not acceptable

29. The Road Ahead

30. In the USA the sex ratio (ie, proportion of male to female births) for whites, blacks, and Asians/Pacific Islanders is 105, 104, and 106 males to 100 females, respectively the probability of delivering a boy in any pregnancy is about 51 percent; this probability remains constant and is independent of the sex of previous siblings and parental age

31. A web based questionnaire assessing preferences for sex of children was answered by 1197 individuals age 18-45 with the following preferences: a family with an equal number of boys and girls (50 percent), more boys than girls (7 percent), more girls than boys (6 percent), only boys (5 percent), only girls (4 percent), and no preference (27 percent) Fertil Steril. 2006;85(2):468.

32. In terms of gender choices, 39% of respondents would like their first child to be a son, 19% would like their first child to be a daughter, and 42% had no preference.

33. When asked would they use preconception sex selection technology, 8% of respondents said yes 74% were opposed, and 18% were undecided. If the sex selection process was simplified to taking a pill, 18% would be willing to use such a medication, 59% were opposed, and 22% were undecided.

34. Sex selection Currently, scientific techniques used to select sex have focused on: Preconception sex selection, which utilizes techniques for sperm separation prior to fertilization, and Pre implantation genetic diagnosis (PGD), which selects the desired sex after fertilization and prior to implantation. Post implantation sex selection –CVS or amnio and abortion

35. Preimplantation genetic diagnosis (PGD) Offers the potential for parents to choose the sex of their children. But who should have access to these techniques? Should they be available only to assist in avoidance of an X-linked disease or should everyone have the option of controlling the sex of their offspring?

36. Ethical Arguments Proponents of sex selection believe that historically couples have been given many choices in reproductive matters, both legally and ethically. individuals should be able to exercise their reproductive choices unless substantial harm to other individuals or to society in general occurs. with selection of sex prior to implantation, postconception selection with pregnancy termination, which is common in many countries, can be avoided

37. Ethical Arguments Those who oppose the use of sex selection believe it could reinforce sex biases or lead to sex ratio imbalances. This is especially relevant in countries where males are highly prized, and sex ratio imbalances already exist. in some areas of China, there are 117 males to 100 females in one rural district of India the ratio is 187 males to 100 females; whereas the worldwide norm is 105 males to 100 females only parents in Spain and Iceland had a preference for female offspring

38. CMAJ 2012 An editorial saying that sex-selection abortions are an issue in Canada and urging doctors to conceal the gender of a fetus until at least 30 weeks to prevent those abortions CMAJ editor-in-chief Rajendra Kale, said that “female feticide happens in India and China by the millions, but it also happens in North America in numbers large enough to distort the male to female ratio in some ethnic groups.”

39. CMAJ 2012 Delaying the information until 30 weeks makes it much more difficult to get an abortion unless there’s a medical reason normal birth ratio is 105 boys to every 100 girls, but it can be as high as 160 boys to 100 girls in some parts of China. a study in India showed that of 7,000 abortions performed there, 6,997 were girls

40. In a study of sex ratios at birth in the United States from 1991 to 2002, the male/female sex ratio for second and subsequent births increased relative to first births for Chinese, Filipino, Asian Indian and Korean populations This is a reversal of the normal trend in the sex ratio with increasing parity and therefore could be indicative of prenatal sex selection

41. Position of major medical societies Preconception sex selection: Should be considered experimental and treated accordingly Couples should be counseled about having unrealistic expectations about the preferred sex Couples need to be fully informed of the risks of failure. Couples desiring sex selection for family balancing must be willing to accept children of the opposite sex if selection fails Couples should be offered the opportunity to participate in research to track and assess the safety, efficacy, and demographics of preconception sex selection Acceptable indications include avoiding an X-linked disease and family balancing American Society of Reproductive Medicine 2006

42. Position of major medical societies Preimplantation genetic diagnosis: The use of IVF with PGD is ethically acceptable for sex selection when a medical indication exists. In patients undergoing IVF, PGD for sex selection for non-medical reasons should not be encouraged. However, the initiation of IVF with PGD solely for nonmedical sex selection should be discouraged. American Society of Reproductive Medicine 2006

43. "Always do the right thing. This will gratify some people and astonish the rest." (Mark Twain)