OTI Online
Winter 1995

Can Separate Be Equal in Women's Health?
OTI Interview with Eileen Hoffman


Dropping the laboring woman on the bed was an ancient method of hastening childbirth among the ancient Greeks in the time of Hippocrates.

New ideas for improving women's health care have been in the air since the highly publicized 1990 U.S. General Accounting Office study which noted how infrequently women are included in clinical trials of new medicines. The most ambitious and comprehensive reform program aired to date is the campaign to create a medical speciality in women's health. To find out how changes in the academy might affect women's experiences in the doctor's office, ON THE ISSUES editor Ronni Sandroff talked to Eileen M. Hoffman, M.D., co-founder of The Women's Health Project, an organization dedicated to educating the public and professionals about women's health as a medical specialty. Dr. Hoffman, clinical assistant professor of medicine at New York University School of Medicine, has a private practice in internal medicine in New York City, and has published numerous papers and given many presentations on this subject.

OTI: At a time when medicine is being criticized for being overspecialized, why do you think we need a new specialty in women's health?

EILEEN HOFFMAN: Women today receive very fragmented medical care. When I began to treat my own women patients, I found that many of them had gone from doctor to doctor with their symptoms. They didn't receive the needed treatment because each doctor viewed them as a collection of the body parts relevant to a particular specialty, not as a whole person.

Let's look at the evaluation of abdominal pain, for example. Gynecologists deal with the pelvis; internists with the abdomen. But in women's bodies, there is no clear anatomical distinction between the abdomen and the pelvis. This is one continuous cavity. The intestines pass through the pelvis and can form tracts into the vagina. Endometrial tissue can migrate up to the diaphragm and cause pleuratic Pung pain. Yet because medical specialists divide women's health, the woman with abdominal pain must often visit two physicians. Each examines her in part and then sends her to the other. There is no continuity of thought or continuity of care. And the social and emotional factors that can affect abdominal symptoms—such as a history of incest, domestic violence —are often completely ignored. When we talk about having a specialty, we refer to training primary care providers in the comprehensive care of women, not training specialists.

OTI: So the problem is that women's reproductive problems are isolated from other health issues?

EILEEN HOFFMAN: The fact that gynecology grew up as our nation's women's health specialty made sense a hundred years ago, when most women's health needs were, in fact, gynecological. Many women died during childbirth; for many others childbirth caused major lifetime disabilities, such as tears between the vagina and the bladder, resulting in incontinence, or prolapsed uterus that made walking and sitting very painful. Other women's health was ravished by untreated venereal disease which caused chronic pelvic inflammatory disease. Maybe this was what the ancient Greek physician Hippocrates was referring to with his famous aphorism: "What is woman? Disease!"

The result was that a surgical specialty, gynecology, took over the responsibility of caring for women. And the rest of medicine was basically let off the hook about thinking about women. Except in the area of reproduction, research findings with men were assumed to be transferable to women. Differences in pathophysiology between the sexes were considered female deviations from male norms. This kept many of the legitimate health concerns of women invisible.

Today, women are no longer leading mainly reproductive lives. In fact, reproduction may never enter the lives of many women. For most of us, it is just one aspect of our lives. We are more than just breasts and a pelvis. Women have hearts, bone, brains, and immune systems. We are living equal lives to men in terms of athletics, education, and professional activities, but our medical and social institutions haven't yet caught up with that fact.

OTI: Won't creating a women's health specialty further "genitalize" medicine, by focusing on our differences from men?

EILEEN HOFFMAN: I see just the opposite. Feminists often get nervous when women are separated out because our differences have all too frequently been held against us. But the push for equality or gender neutrality has not served women well in medicine. We need to move to an appreciation of the fact that women and men are different; to recognize these differences respectfully.

There is no "gender neutral" human being we can study. So, in fact, up until very recently, clinical and animal studies basically examined men and ignored women. It was a simpler approach, because studies weren't interfered with by women's menstrual cycles or pregnancies. Gender neutrality has kept women invisible.

Today physicians prescribe drugs to women that have only been studied in men. We perform surgical procedures with tools designed for the larger male body. We make interpretations about normal emotional development and psychiatric illness based on studies of men.

We have not only a fragmented delivery system; we have a fragmented data base from which doctors are trained. A case in point: we're now sophisticated enough to understand that the sex steroids, most notably estrogen, do a whole lot more than affect reproductive function. Estrogen acts on the uterus to produce a baby, but it also interacts with every single one of our organs, be it the heart, the bones, the skin, the immune system, or the brain—whether or not a woman ever becomes pregnant.

Yet only gynecologists study ovarian endocrinology. Today estrogen has entered into the internists' pharmacopoeia of cardiac active drugs. If we are going to be using estrogen to treat heart disease, we need to train doctors to know how our ovarian hormones interact with our organ systems.

OTI: There's a fear that separate will never be equal, that dividing female from male medicine will ghettoize women's health and lead to even less adequate treatment.

EILEEN HOFFMAN: Women's health is already "ghettoized"—to a surgical specialty focusing only on reproductive health. Even early feminist efforts to improve women's health care did not break out of that concept.

When Our Bodies, Ourselves was originally published in 1969, the feminist movement challenged the power relations between women patients and male physicians. But it retained the assumption that reproductive health could be equated with women's health. This narrow focus did nothing to challenge women's relative exclusion from the non-reproductive aspects of medicine.

The exclusion has been almost comical. For example, it was long known that premenopausal women were relatively immune from coronary artery disease. But this information was not used to treat heart disease in women—although it is the number one cause of female death. Instead, in the heyday of heart-attack hysteria, estrogen was given to men!

In the last four years we have seen dramatic change in our concept of women's health. The Women's Congressional Caucus spurred the federal General Accounting Office to study the issue, and in 1990 it released a ground breaking report criticizing the National Institutes of Health for their failure to include women adequately in clinical trials. This one statement of fact, at this particular time in history, raised to new levels the nation's consciousness about women's health. It occurred within a cultural climate ready to receive it—a climate poised to respond to women's demands for inclusion. This time women will not resort to alternatives outside mainstream medicine. Instead they, and their male allies, intend to change the system to meet the legitimate needs of women.

I believe that creating a place within the hierarchy of medicine devoted to the comprehensive care of women from a woman-defined perspective is the only way to assure that it will not be marginalized and that every medical student receives training in women's health.

OTI: Do we need a specialty in men's health, too?

EILEEN HOFFMAN: No. We're already concentrating most of our efforts on male medicine.

When pediatrics was developing as a specialty, many people argued that it was unnecessary. In fact, I'd like to see a specialty in women's health modeled after pediatrics, with its emphasis on the whole child. Pediatrics has set a precedent for taking social context into account when you are concerned about the health or illness of the child. A pediatrician often looks at how a child functions in the family, in its peer group, in the schools, with law enforcement, as a way of judging health or illness. And pediatricians advocate on behalf of children when they are not functioning well in those settings. Maybe that's why we've done a little better job of dealing with child abuse than domestic violence.

OTI: How do you see the "social context" applying to women's health?

EILEEN HOFFMAN: I often feel that if I didn't take the time to really understand my women patients' backgrounds and personal histories, that I would be misdiagnosing and mistreating them most of the time. The health status of women is intimately connected to their political and economic subordination.

It is when physicians focus on the whole person within the context of their life that real strides in understanding health and coping with illness occur. If medicine had always included women on par with men, violence would have long ago been identified as a problem of epidemic proportion. It would be understood as the primary etiology of disturbances we now categorize as multiple personality disorder, borderline personality, eating disorders, substance abuse, somatization, chronic pelvic pain, Engraving of a birth scene, Basel, Switzerland, 1500 and "too frequent" utilization of health services. Male aggression would become a leading psychiatric diagnosis and millions of dollars would be spent researching the causes and treatments of this life threatening and totally preventable disorder.

Many of the most crucial women's health concerns reside outside the traditional biomedical model. Poverty and violence disproportionate affect women. Societal concepts of sexuality, physical appearance, self-esteem, and body image produce a whole array of problems that are not recognized by the current medical system.

Most physicians are unprepared to diagnose and treat emotional disorders. Yet approximately 20% of all patients visiting primary care physicians suffer with well-defined mental disorders; the number rises to 40% if minor disorders are included.

Women's normal life transitions, as well as such serious emotional problems as eating disorders, chemical dependency, depression, anxiety, childhood sexual abuse, rape, domestic violence, and their sequelae, are poorly conceptualized within traditional medical school and postgraduate curricula. Physicians rarely diagnose and appropriately treat these common problems in women leading to residual and unnecessary disability.

OTI: You often read that women are the main users of the health-care system and account for many more doctor and hospital visits than men. Some commentators have cited this as proof that the system serves women well.

EILEEN HOFFMAN: It is curious to me that women keep coming, when the number one complaint that women have about their doctors is that they feel unheard and unseen.

One reason is that women are trained to use the health-care system at an early age for menstrual problems, contraception, childbirth, routine pap screenings, and so on.

Another reason is that the medical environment may be one of the only places women can focus energy on themselves, instead of taking care of others.

Another possible reason for women's so-called overuse of the system is that patients continue to seek satisfaction. The Commonwealth Fund's Commission on Women's Health did a survey last year which showed that 41% of women changed physicians within the last year, and that by and large the major reason was that the women felt there was poor communication. Twenty-five percent report "being talked down to" by their doctors. Another 17% said they were told their symptoms were "all in their head."

The health-care system is not set up to meet women's interests and needs to make decisions contextually and collaboratively. Our personal medical decisions often have large effects on the other people in our lives. This is not fully understood in the health-care system. Many male doctors may be interested in boiling everything down into its essence: Making a diagnosis, writing a prescription and feeling that he has completed his business. But this does not always fill women's needs.

Appropriate doctor/patient communication is not just a nice frill. Studies have shown that high blood pressure and diabetes are better controlled when there is good communication between doctors and patients.

So reducing fragmented care by training one specialist to provide contextual, comprehensive primary care to 52% of the population—and an even larger proportion of users of the health-care system—may help hold health costs at a reasonable level while actually increasing quality of service.

And we do need to extend care to more women. According to the Commonwealth Fund's Commission on Women's Health, 36% of uninsured and 13% of insured women do not receive needed care. Because women are more likely than men to be poor and employed part-time or not at all, they are less likely to have access to needed medical care than men. Within the current paradigm, older women, poor women, women of color, disabled women, lesbians and bisexual women, in particular, very rarely receive the level of care appropriate to their needs. More than one-third of women do not seek or receive Pap smears, mammograms, pelvic exams, breast exams, or a complete physical. The rate is even higher for elderly women. Many women have significant risk factors for heart disease, lung cancer and osteoporosis, but no knowledge of risk reduction.

OTI: What do you say to the charge that a women's health speciality is simply a marketing tool, or that it's designed to solidify the power of women physicians?

EILEEN HOFFMAN: Many of the "women's centers" now being developed by hospitals are, indeed, just a marketing tool. Pink curtains in the dressing rooms may be the only significant change. The centers are created to do tests on women—bone scans, mammograms, and so on. Many centers do not offer comprehensive, integrated medical care. So I understand why people are wary.

Some critics are concerned that a specialty in women's health will attract predominantly female providers, which will make it less prestigious and underpaid. It's true that women doctors are leading the efforts in women's health-care reform. This has led some male physicians to suggest that a specialty in women's health may be just a ploy by female physicians to corner the market. And there are some male physicians who worry about their economic futures, now that women patients explicitly prefer women physicians—a kind of arbitrary discrimination men have rarely experienced. But let's be clear: Women's health refers to the sex of the patient, not the sex of the physician.

The need for a specialty becomes clearer when you consider nutrition. No physician questions the value of good nutrition in maintaining maximum health and speeding recovery from medical conditions and surgical treatments. However, physicians cannot specialize in nutrition and most medical students have little or no nutritional training. The same fate awaits women's health unless it becomes a specialty. Currently, students and physicians interested in women's health must make a personal effort to learn about the field.

So it is not until women's health is institutionalized and becomes a focus for research that substantive changes will be realized. I think the only way to assure that women receive medical care on par with men is the development of a formal interdisciplinary primary care specialty in women's health. Training would include sex- and gender specific information assuring that women's health and illness is examined within the context of their complex hormonal and social milieux. Politically, it is from the power base of a specialty in women's health that efforts to mainstream better treatment into the internist's office and the gynecologist's office are most likely to be successful.

A specialty in women's health will be an explicit acknowledgement from the medical profession to women that it will no longer use men as the standard. I think it should be the next demand of the feminist movement in the health arena. This is an excellent way for medicine to regain the trust it has lost among women patients.

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