The New York Times Sunday Review - The Opinion Page
By LAURIE EDWARDS
Published: March 16, 2013
TO the list of differences between men and women, we can add one more:
the drug-dose gender gap. Doctors and researchers increasingly
understand that there can be striking variations in the way men and
women respond to drugs, many of which are tested almost exclusively on
males. Early this year, for instance, the Food and Drug Administration
announced that it was cutting in half the prescribed dose of Ambien
for women, who remained drowsy for longer than men after taking the
Women have hormonal cycles, smaller organs, higher body fat
composition — all of which are thought to play a role in how drugs
affect our bodies. We also have basic differences in gene expression,
which can make differences in the way we metabolize drugs. For
example, men metabolize caffeine more quickly, while women metabolize
certain antibiotics and anxiety medications more quickly. In some
cases, drugs work less effectively depending on sex; women are less
responsive to anesthesia and ibuprofen for instance. In other cases,
women are at more risk for adverse — even lethal — side effects.
These differences are particularly important for the millions of women
living with chronic pain. An estimated 25 percent of Americans
experience chronic pain, and a disproportionate number of them are
women. A review published in the Journal of Pain in 2009 found that
women faced a substantially greater risk of developing pain
conditions. They are twice as likely to have multiple sclerosis, two
to three times more likely to develop rheumatoid arthritis and four
times more likely to have chronic fatigue syndrome than men. As a
whole, autoimmune diseases, which often include debilitating pain,
strike women three times more frequently than men.
While hormonal, genetic and even environmental factors might influence
the manifestation and progression of autoimmune diseases, we don’t yet
know the reason for this high prevalence in women.
Pain conditions are a particularly good example of the interplay
between sex (our biological and chromosomal differences) and gender
(the cultural roles and expectations attributed to a person). In 2011,
the Institute of Medicine published a report on the public health
impact of chronic pain, called “Relieving Pain in America.” It found
that not only did women appear to suffer more from pain, but that
women’s reports of pain were more likely to be dismissed.
This is a serious problem, because pain is subjective and
self-reported, and diagnosis and treatment depend on the assumption
that the person reporting symptoms is beyond doubt.
The oft-cited study “The Girl Who Cried Pain: A Bias Against Women in
the Treatment of Pain” found that women were less likely to receive
aggressive treatment when diagnosed, and were more likely to have
their pain characterized as “emotional,” “psychogenic” and therefore
Instead of appropriate care for physical pain, this can lead to
treatment for mental health issues that might not even exist. The
situation is further complicated by the fact that antidepressants are
absorbed differently in women and vary in effectiveness, depending on
The routine attribution of abdominal pain from conditions like
appendicitis or gastrointestinal disease to gynecological problems can
also delay or complicate the diagnostic process. A 2008 study
published in the journal Academic Emergency Medicine, designed to
gauge gender disparities among emergency room patients complaining of
abdominal pain, found that even after adjusting for race, class and
triage assessment, women were still 13 to 25 percent less likely than
men to receive high-strength “opioid” pain medication. Those who did
get opioid pain relievers waited an average of 16 minutes longer to
Conditions like fibromyalgia or chronic fatigue syndrome, for which
definitive causes have not been identified and concrete diagnostic
tests are not available, illustrate the problems associated with the
perceived reliability of the female patient as narrator of her pain.
Women are more likely to receive diagnoses of many of these more
nebulous conditions — fibromyalgia, which affects about six million
patients in the United States, is nine times more likely to be
diagnosed in women than in men — and this discrepancy surely
contributes to the widespread skepticism that still exists over the
legitimacy of these disorders.
I AM a sufferer of pain and chronic disease. Like many, I’ve had
physical symptoms (in my case, respiratory problems and infections)
explained away as emotional. My freshman year in college, I was in the
emergency room, flanked by machines and struggling to breathe while
doctors lobbed questions at me: Why wasn’t I responding to the
medication the way they expected I would? Was I just too anxious?
Could I not handle stress, and was that making me sick?
I was 23 before I was given a correct diagnosis of a rare genetic lung
disease called primary ciliary dyskinesia. I’d been sick since birth,
but long diagnostic journeys are occupational hazards of living with
conditions doctors don’t often see. Still, my journey was
unnecessarily protracted by my doctors’ dismissal of my symptoms as
those of a neurotic young woman.
For all the medical advances of the past few decades, we still know
shockingly little about pain and how to control it. Sex-based research
is a crucial part of understanding not just the underlying mechanisms
of pain, but the most effective ways to treat it for men and women
alike. The Institute of Medicine report found gaps in research,
particularly in terms of effective treatments, as well as in the
oversight of pain research. The report recommended that these problems
be addressed and that strategies to resolve them be implemented by
Among those improvements must be a renewed focus on discovering why
women respond differently to some drugs and diseases, as well as an
emphasis on training physicians to better diagnose and manage women’s
pain. A report by the Campaign to End Chronic Pain in Women found that
inadequate physician training in diagnosing and treating just six pain
disorders that affect women either exclusively or predominantly,
including fibromyalgia and chronic fatigue syndrome, added as much as
$80 billion a year to America’s health care bills.
Part of the reason the diagnosis and treatment of women’s pain lag so
much is simply the pace of medical research itself, which is slow to
move from publication to clinical practice. Unfortunately, if
anything, changes in assumptions about gender evolve even more slowly.
Laurie Edwards is the author of the forthcoming book “In the Kingdom
of the Sick: A Social History of Chronic Illness in America” and a
writing teacher at Northeastern University.
The New York Times Sunday Review - The Opinion Page