Sex, gender and health: is history repeating itself? (EN)
I like it when my personal life provides me with perfect examples to use in my working life. Last week, I had a discussion with my 84-year-old grandma on the phone. She couldn’t hear me very well, as my boyfriend was vacuuming. After I explained where the noise came from, she was surprised. She figured it was my job, as a woman, to do household chores. This is a perfect example of gender: the socially prescribed and experienced behaviors, roles and identities of people, based on them being male or female. Gender is shaped over time and place, thus it is only natural my view in this differs from my grandma’s view. Although this is an innocent example, the influence of gender on one’s health is much more serious!
In my PhD research I explore how gender and sex may influence our health: I seek to understand to what extent sex and gender associate with, for example, the severity andlongevity of common somatic symptoms [1,2]. But how does gender exactly differ from sex? Well, you could think of gender as the psychosocial equivalent of biological sex. Sex refers to biological characteristics, including but not limited to genes, hormones and anatomy of male and female bodies. Gender is a socially constructed concept, sex is a biological concept. Gender and sex are definitely not the same, but both affect people’s health, in more ways than you initially may think.
Sex and disease Why do we even look into sex and gender and their relation with health? We are all well aware of the impact sex has on health. Sure, males won’t develop ovarian or cervical cancer and females don’t need a prostate exam. That’s just common sense, right? Although I’m not sure it’s an urban myth, but among sex and gender researcher the anecdote of a 1970s pilot study investigating a potential treatment for cervical cancer in a completely male (!) study sample is often told. I like to think these investigators had common sense too.
I hear you thinking: ‘In the meantime, 50 years has passed. It must have changed by now right?’. Off course progress had been made. For example, Go Red For Women is an initiative that raises awareness for heart conditions in females by asking people to wear red one day a year. Many people are nowadays aware that female heart symptoms differ from male heart symptoms. Nevertheless, if you Google ‘heart attack’ images, some infographics about sex differences in heart attacks pop up, but most pictures are males clamping their chest. Apparently there’re no stock photos of women suffering from a heart attack, as if women are not affected by heart attacks?*
*Sabine Oertelt-Prigione showed me this example some time ago, but my Google search of March 2021 shows that it’s still true!
Additionally, there’s more to sex than just male or female bodies. For example, intersex variations are unknown to two-thirds of the Dutch and Flemmish people . Intersex variations comprise bodies that deviate from the binary male and female idea. For instance, some people may have what we call ovotestes. This means that both ovarian and testicular tissue is present in one individual. Consequently, people with ovotestes may develop malignancies in both these types of tissues. Although intersex variations and their implications for health are wildly interesting, there’s so much to discuss that these deserve a blog on their own. Nevertheless, it is good to realize that there’s more to sex than just male and female bodies and that this affects health.
Gender and disease What about gender? Gender influences health in many ways: it is thought that gender influences risk-taking behavior. If you want to have a good laugh, please read the BMJ Christmas article on gender and risk-taking behavior “The Darwin Awards: sex differences in idiotic behavior”, #SorryNotSorry guys . Gender also associates with the prevalence of disease: thinking back of the 2014 Ebola epidemic in Western Africa, it were predominantly women who taking care of the ill and the deceased, who remained contagious after death. This exposed more women to the virus than men .
Back in the days… History has undoubtedly shaped our current healthcare philosophy with regards to sex and gender. We can’t deny that historically female bodies were considered inferior to male bodies. Through history, female bodies were often seen as nothing more than reproductive machinery . The idea that women and men merely differed in their reproductive organs made studying anything other than female reproductive organs in women unnecessary. After all, everything else could be studied in men, right?
This strong focus on female reproductive organs was already present during the Greek era. Greek physicians and philosophers such as Hippocrates and Plato figured that it was the uterus, which has no male equivalent, that was the ‘fault’ for conditions that affected women. You see, sometime the uterus could wander (silly reader, all this time you were thinking a uterus was fixed in the female’s lower abdomen, right?) But no, dear reader… Up, down, left and right: the direction in which the uterus wandered, was linked to specific diseases according to the Greeks. Up, for example, caused headaches. In all honesty, if my uterus just wandered into my torso somewhere near my heart, I think I would have more to worry about than just headaches... In the Middle Ages the idea of the wandering uterus was still prevalent: the uterus wandered through the body in search of a child.
Among medical scientists during the 17th and 18th century the common idea was that female bodies’ function was childbearing. Early anatomical sketches of skeletons intentionally depicted females’ hips wider (i.e. suitable for childbearing) and their craniums smaller (i.e. not as smart as men). Up until the 19th century, the uterus was to blame for female-specific complaints, and even for complaints that weren’t linked to the female bodies. Basically, the uterus was to blame for anything and everything a woman experienced. A great example of that time is the catch-all diagnosis of hysteria in women. Symptoms of hysteria were shortness of breath, fainting, irritability, a decreased libido, but funnily enough also an increased libido and any kind of rebellion (but truly feminism) – in short, hysteria was associated with ‘difficult women’. I think, in this day and age we can state that women with an opinion were diagnosed with hysteria. Treatments for hysteria focused on the womb: from massaging it, to hysterectomies. Hysteria was only removed from the DSM, the diagnostic manual of mental disorders, in 1980.
Thus, based on their sex (female reproductive organs) and gender (taking a feminist rebellious approach to gender roles) women were diagnosed with hysteria in the past.
So… Now what? Circling back to the question asked at the beginning: is history repeating itself when it comes to sex, gender and health? I’d like to say that the tide is changing. My PhD research is just one example of increased awareness about sex and gender in medicine and research: we developed a novel method to assess gender roles in cohort studies, facilitating gender-related research in studies that did not originally include a gender measure in their studies. We are also thinking about how to include items in questionnaires that are informative and sensitive when asking for participants’ sex (including intersex variations). And we’re just starting: much more research exploring sex, gender and health is done around the globe. Thus… To be continued!
Aranka Viviënne Ballering
University: University of Groningen/University Medical Center Groningen
Research programme: Interdisciplinary Center for Psychopathology and Emotion regulation (ICPE).
Favorite drink: Usually tea, but I won’t turn down a Piña Colada on a hot summer day 😊
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Do you want to know more? Check out https://www.rug.nl/staff/a.v.ballering/research for Aranka's personal profile and research articles. You can also find more information on the multidisciplinary research on sex- and genderdifferences on the following website: https://symptomengender.ruhosting.nl/.
 Ballering, AV., Bonvanie, IJ., Olde Hartman, TC., Monden, R., Rosmalen, JGM. (2020). Gender and sex independently associate with common somatic symptoms and lifetime prevalence of chronic disease. Social Science & Medicine, 253, 112968.
 Ballering, AV., Wardenaar, KJ., Olde Hartman, TC., Rosmalen, JGM. (2020). Female sex and femininity independently associate with common somatic symptom trajectories.Psychological Medicine, 1-11. doi:10.1017/S0033291720004043
 Rutgers. (2021) Slechts 1 op 3 van de Nederlanders en Vlamingen weet wat intersekse is. Retrieved from: https://www.rutgers.nl/nieuws-opinie/nieuwsarchief/slechts-1-op-3-van-de-nederlanders-en-vlamingen-weet-wat-intersekse
 Lendrem, BAD., Lendrem, DW., Gray, A., Isaacs, JD. (2014). The Darwin Awards: sex differences in idiotic behaviour. BMJ Lendrem, B. A. D., Lendrem, D. W., Gray, A., & Isaacs, J. D. (2014). The Darwin Awards: sex differences in idiotic behaviour. BMJ, 349, doi: https://doi.org/10.1136/bmj.g7094.
 Ballering, AV. (2020). Corona: verschillende gevolgen voor mannen en vrouwen? Retrieved from: https://symptomengender.ruhosting.nl/blogg-22-bezonnen-lezingen-over-gender-gezondheid/#more-995
 Jackson, G. (2019). The female problem: how male bias in medical trials ruined women’s health. Retrieved from: https://www.theguardian.com/lifeandstyle/2019/nov/13/the-female-problem-male-bias-in-medical-trials