False Diagnosis
When it comes to gender, doctors don't play favorites.
Among the feminist causes of the 1990s, few had a broader or more powerful appeal than women's health. Who could fail to be outraged by the charge that a male-dominated, gender-biased medical establishment had endangered women by giving the lion's share of attention to men? But maybe the outrage should have been directed at the accusers, not the accused. Today, a little over a decade after this crusade moved into the spotlight, the feminist indictment of medical sexism has been largely discredited -- but not before infecting the discussion of health care with rancorous gender politics and provoking equally misguided claims of victimhood from some men.
Not long ago, groups such as the National Women's Health Network (which declared in a 1994 fundraising letter that "Medical research has mainly been done on men, for the benefit of men only") found an eager audience among journalists and politicians. Former Rep. Pat Schroeder (D-Colo.) noted that mostly male researchers "are more worried about prostate cancer than breast cancer"; Health and Human Services Secretary Donna Shalala lamented that health care had been addressed from "the white male point of view." Bill Clinton vowed that women would never again be "second-class citizens" in medical research and care.
The evidence that women had been "shortchanged" seemed powerful. Major studies of coronary heart disease had been limited to men. The most notorious example was a study published in 1989 concluding that aspirin helps prevent heart attacks; it had used a sample of 22,000 male physicians and not one woman. More outrage was fueled by reports that the National Institutes of Health spent just 14 percent of its budget on women's health and failed to ensure women's adequate inclusion in clinical trials.
Under pressure from the Congressional Caucus for Women's Issues, an Office for Research on Women's Health was established at the NIH in 1990. Three years later, to the dismay of many medical professionals who warned against letting politicians dictate research priorities, Congress passed legislation requiring all federally funded clinical studies to include enough women and minorities to analyze the findings by sex and race. One could argue that heavy reliance on government funds inevitably invites such intervention, but that doesn't excuse the pols who wield the blunt instruments, especially when their intervention is based on myth.
In fact, as Yale Medical School lecturer Sally Satel convincingly demonstrates in her recent book, PC, M.D.: How Political Correctness Is Corrupting Medicine, the notion that until recently women were left out of medical research is sheer nonsense. (See "Shrink Control" on page 55 for a review of Satel's book.) As far back as 1979, more than 80 percent of NIH-funded trials included both sexes, while three-quarters of the rest were all-female. If female-specific health problems received only 14 percent of the NIH's research budget, then male-specific ones got only half as much.
Satel's conclusions are supported by an article in the October 2000 issue of the medical journal Controlled Clinical Trials, based on an extensive analysis of medical literature since 1966. The authors, Johns Hopkins public health professors Curtis Meinert and Adele Gilpin and their colleagues, found that 17 percent of clinical trials reported in American medical journals before 1975 were male-only and 9 percent were female-only (a disparity possibly due to the use of Veterans' Administration hospitals as convenient study sites). In the next two decades, single-sex trials were more or less evenly split between men and women. In cancer research, all-female trials outnumbered all-male ones more than two to one from 1966 to 1985.
And those all-male heart disease trials? Actually, even some women's health advocates, such as Vivian Pinn, director of the Office of Research on Women's Health at the NIH, have conceded that there were compelling reasons to limit them to men. When studying heart attack prevention, it makes sense to start with a group in which one can expect a relatively high rate of heart attacks. Men are three times more likely than women to die of a heart attack before age 65. Plenty of other cardiovascular research did include women -- especially major observational studies, from the Framingham Heart Study, launched in 1948, to the Nurses' Health Study, which began in 1976. And other conditions, from hypertension to diabetes, were extensively studied in both sexes long before women's health became a political issue.
The mother of all women's health myths is that breast cancer was shortchanged because of gender bias. From 1966 to 1986, there were over 400 clinical trials on breast cancer and 121 on prostate cancer; and in 1990, the National Cancer Institute spent $81 million on breast cancer research and $13.2 million on prostate cancer, which causes nearly as many deaths (albeit at a later age).
Did the women's health advocates have legitimate concerns? Sure. The perception of heart disease as a "man's problem" did exist; there were credible horror stories of the patronizing treatment women often encountered at doctors' offices. But all this could have been addressed without misleading and polarizing rhetoric about the evils of "male medicine."
In recent years, women's health -- viewed as a sure way to the hearts of soccer moms -- has become a pet cause for politicians, often with dubious results. Bills requiring insurance companies to cover longer hospital stays for certain procedures almost invariably focus on female-only conditions such as childbirth or breast cancer surgery. Politicians have even gotten into the business of dispensing medical advice. In 1997, the Senate browbeat the NIH into reversing a statement that routine annual mammograms should not be recommended for all women in their 40s. (An NIH panel had concluded that for women under 50, the risks of a false positive diagnosis and unnecessary surgery most likely outweigh the benefits of mammography.)
Many researchers are particularly worried about growing demands that all findings of clinical studies be analyzed by gender. Satel argues that significant sex differences in reactions to medical treatments are rare, and that a blanket effort to ferret out minor differences will cause research costs to skyrocket and possibly delay the approval of lifesaving drugs.
Meanwhile, the drive to recruit more women into clinical trials has succeeded so well that men's enrollment in NIH-funded studies has dropped from about 45 percent of the total in 1994 to 32 percent in 1998. In cancer research -- where, far from playing catch-up, women have been over-represented for a long time -- men now account for just 29 percent of the subjects.
Enter the men's health movement, which has been fairly successful in pushing for more research on prostate cancer -- and may be on the verge of a big symbolic victory. In February, Rep. Randy Cunningham (R-Calif.) introduced a bill that would establish an Office of Men's Health within the Department of Health and Human Services. The Men's Health Act is rapidly gathering bipartisan support and seems likely to pass.
Men's health advocacy groups such as the Men's Health Network and Men's Health America have raised some important issues; most laudably, they have helped debunk the notion of women as victims of medical gender bias. Unfortunately, they often seem to use one brand of victim politics to drive out another -- and to take us further down the road of turning health care into a gender issue.
Interestingly, some of the strongest criticisms of proposed government action for men's health come not from feminists but from people whom men's health activists have long viewed as allies: Satel, Meinert, and Andrew Kadar, a physician at Cedar Sinai Hospital in Los Angeles who took on the myth of male-biased medicine in The Atlantic in 1994. "I sympathize with the impetus of the men's health movement," says Satel, who agrees that health care priorities have been skewed by pressure from the women's lobby and that advocacy for men may be needed to restore the balance. "But I don't think we need a new federal bureaucracy to deal with these issues."
The critics are also put off by the alarmist language of the Men's Health Act, which opens with the declaration that "A silent health crisis is affecting the health and well-being of America's men." By most measures, the health and well-being of all Americans are better than ever. The bill also notes that the life expectancy gap between men and women has grown from one year in 1920 to almost six years in 1998. Yet, apart from the fact that both sexes have gained more than 20 extra years of life over the same period, this assertion overdramatizes the reality. Women already outlived men by an average of three to four years by 1910 (the 1920 figure was a fluke). And now the longevity gap is not widening but shrinking -- from 7.8 years in 1979 to 5.6 years today -- due partly to inroads against heart disease in middle age.
Moreover, the men's health movement dogma that men's shorter life expectancy gap is due to neglect of men's health rather than biology is as unreasonable as the feminist dogma that all sex differences are a social construct. It's true that this gender gap didn't show up until the 20th century -- mainly, Kadar suggests, because infectious diseases used to kill off a lot of people before they reached middle age, when men's greater susceptibility to heart disease and cancer manifests itself. He believes that, while women's greater average longevity may be partly due to the fact that women are more active in seeking medical help, to suggest that changes in health care can eliminate this differential is simply misleading.
Generally, men's heath advocates have steered clear of the gender antagonism that has often marked women's health activism; they rarely miss an occasion to stress that improvements in men's health will benefit women. Still, they can lapse into bitter rhetoric that eerily echoes the feminists. A passage from an article by a men's rights activist recently posted on the Men's Health America message board asserts that "we simply don't care much about men" and deplores "the devaluation of male lives."
Most critics of the women's health movement find that the male version of the victim mentality isn't much better. "I think the partisan approach to medicine leads us to places where we shouldn't be going," says Meinert. "This approach doesn't benefit us as human beings."
Apart from these philosophical concerns, there are reasons to worry that, like its female counterpart, men's health advocacy may end up putting "sensitivity" toward men above sound medical judgment. In a parallel to the mammography debate, men's groups champion universal, regular prostate cancer screening for men over 50, even though the controversy over its benefits and risks is far from resolved.
"When it comes to America's health- care crisis, it's about time we started treating men as well as we treat women," wrote Armin Brott, a Men's Health Network board member, in a recent newspaper op-ed. Does this mean turning men into another special interest group? Maybe it's time we started treating both women and men as human beings who deserve concern and respect, not paternalism and pandering.
