Gender medicine is likely to be one of the most important fields of research over the next few decades. However, it was not until the 1980s that people began to notice differences between the sexes with some illnesses and diseases. “Heart attacks, which manifest themselves differently in women and in men, are a classic example,” Teresa Gisinger says. She is a physician and a member of the research group led by Alexandra Kautzky-Willer, Head of the Gender Medicine Unit at the Medical University of Vienna. In addition to a person’s biological sex, the researchers are also interested in how their gender impacts their health. “Being a psycho-social and socio-cultural construct, gender is particularly difficult to analyze,” Kautzky-Willer explains. “Plus there’s the fact that parameters associated with gender – such as gender identity, gender relations, gender roles, and institutionalized gender – have been largely ignored by medical studies up until now, starving us of the data we need to run analyses.”
To enable gender influences to be measured retrospectively nonetheless, the researchers joined forces with colleagues from Canada, Italy, Sweden, and Spain. Forming the “Gender Outcomes INternational Group: to Further Well-being Development,” or GOING-FWD for short, they set out to investigate the social dimension of gender differences in the context of several chronic conditions. Among other things, they established that people who identify as women are at increased risk of cardiovascular disease. Women and those who identify as such – i.e. who might be biologically male – also have a harder time accessing the health service. These findings highlight the need to raise awareness of gender differences among those involved in medical research and treatment, something for which the new method devised by the GOING-FWD group can deliver some key insights.
Using the gender score to make assessments
The large-scale study drew on past health surveys from the individual countries that had involved over 30 million participants in total. Kautzky-Willer and Gisinger scanned their data for gender-specific clusters that were distinct from those attributable to biological sex. “Before we launched the project, Louise Pilote from McGill University in Canada had devised a method we can use to make gender measurable in a ‘gender score,’” Kautzky-Willer says. “To do this, we start by identifying gender-specific factors in a particular data record, such as: ‘What’s the person’s employment status?’, ‘How many people do they share a household with?’, ‘Who’s the main breadwinner in that household?’, and ‘Who does the housework?’”
A gender model is then constructed out of these elements, with the allocations of factors to a female- or male-oriented gender taken solely from the data. “Instead of presuming from the outset that women earn less, say, we use biological sex to build a model from which we can ‘read off’ associations of this kind,” Gisinger says, explaining their method. “The sex element is not removed from the model until the second stage, thus leaving those social factors that go toward determining the gender score.” Thus, although a female-oriented gender score is associated with the characteristics of someone who is biologically a woman, it can also be achieved by a man who earns a low income or does unpaid work as a carer. In other words, the current model is binary in nature, something that the researchers believe has the potential to be expanded for future analyses. Nevertheless, they have managed to obtain some key insights from the first-ever study of this kind and size.
Poorer heart health, less blood sugar management
“The project has given rise to more than 50 publications in all,” Kautzky-Willer reports. Investigations have looked at the impact of gender on cardiovascular and neurological conditions as well as metabolic disorders, chronic kidney disease, and – with the pandemic hitting during the course of the study – COVID-19 as a single acute infectious disease.
Kautzky-Willer and Gisinger had a major hand in many of the results, including the investigations into cardiovascular conditions. This involved them analyzing the cardiovascular risk profile of women and men (based on sex), taking into account factors such as smoking, lack of exercise, increased weight, and high blood pressure. “We found that women have a better risk factor profile and are less likely to suffer from cardiovascular conditions,” Kautzky-Willer reveals. “When we looked up the gender score, ignoring the sex element, people who identified as women had poorer heart health.” Their findings thus highlight the significant influence that socio-cultural aspects of gender have on this group of diseases. “It’s especially interesting given that women have better protection against cardiovascular conditions because their estrogen levels are higher,” Gisinger says. “So our results show that, although women might have some biological advantages, female gender plays a greater role in the emergence of cardiovascular diseases.”
In another publication, the group of researchers looked at the influence of gender on prognoses of diabetes mellitus and access to healthcare services. Their study showed that diabetes patients who identify as women have their hba1c levels measured less often – this is a parameter that indicates how effectively the body is regulating blood sugar and that is thus used as a monitoring tool. Austria scored worse than Canada on this count in a direct comparison, even though the two countries are similar in terms of their welfare systems and their position in the United Nations Gender Inequality Index. Within Europe, the medical care afforded to people who identified as women deteriorated the higher up the gender equality index one went.
Straddling medicine, research, and politics
“What’s most important for us as clinicians is to be aware of the gender differences and be able to act accordingly,” Gisinger explains. In addition, she believes that the study findings should prompt medical researchers to include gender-associated parameters in their own investigations in the future and break their results down accordingly. “Ultimately, however, this will also enable some key socio-political demands to be formulated as a result,” Kautzky-Willer adds. “Whilst a person’s biology can only be changed to a very limited extent, their gender score can most definitely be influenced. Wherever a certain group of people are being treated unfairly and put at a disadvantage in terms of their health, we can and must bring about a change in gender roles.” In her view, this will require action to reduce gender differences and break down stereotypes as well as funding for gender medicine projects and further training in the healthcare sector. “People are growing increasingly aware of gender medicine, and we should make sure we stay on the ball,” exhorts Gisinger.
Alexandra Kautzky-Willer is Head of the Clinical Division of Endocrinology and Metabolism at the Medical University of Vienna. She also heads up its Gender Medicine Unit, where Teresa Gisinger is studying the influence of gender factors on common diseases for her PhD. Both physicians played a major role in the transatlantic “Gender Outcomes INternational Group: to Further Well-being Development,” or GOING-FWD for short. Their large-scale study was awarded EUR 298,553 in funding from the Austrian Science Fund FWF and concluded in January 2023 at the end of its four-year term.
Gisinger T., Azizi Z., Alipour P., Harreiter J., Raparelli V., Kublickiene K., Herrero M.T., Norris C.M., Emam K.E., Pilote L., Kautzky-Willer A.: Sex and gender aspects in diabetes mellitus: Focus on access to health care and cardiovascular outcomes, in: Frontiers in Public Health Feb. 2023
Azizi Z., Gisinger T., Bender U., Deischinger C., Raparelli V., Norris C.M., Kublickiene K., Herrero M.T., Emam K.E., Kautzky-Willer A., Pilote L.: GOING-FWD Investigators: Sex, Gender, and Cardiovascular Health in Canadian and Austrian Populations, in: Canadian Journal of Cardiology 37(8), Aug. 2021