Duke Medical Ethics Journal
How Gender Bias and Andronormativity Affects Women in Healthcare
By: Alexis Mosu
Jennifer Brea was a perfectly healthy twenty-eight year old who had traveled the world and was in school to earn her Ph.D. and become a social scientist. Then, a fever of one hundred and four degrees marked her progression into a very serious illness, what she now knows to be a debilitating case of myalgic encephalomyelitis, or chronic fatigue syndrome, but for years doctors told her the crippling pain, dizziness, and disorientation she felt regularly was all in her head. “The ignorance surrounding my disease has been a choice,” she said in a Ted Talk in 2017, “a choice made by the institutions that were supposed to protect us…Forty-five percent of patients who are eventually diagnosed with a recognized autoimmune disease are initially told they’re hypochondriacs. Like the hysteria of old, this has everything to do with gender and with whose stories we believe,” . Gender bias in medicine is a form of discrimination
that for centuries has yielded “medically unmotivated differences
in the treatment of men in women”  and most frequently
marginalizes women like Brea based on a stigma that leads to
millions of misdiagnoses each year. This stigma is a result of
systematic andronormativity—defined as “a state of affairs where
male values are regarded as normal to the extent that female
values disappear or need to be blatantly highlighted in order to
be recognized” —in medical research and the development
of foundational medicine throughout history. Gender bias does
not only result in misdiagnosis or delayed diagnosis for female
patients, but also produces emotional and psychological damage
as women are most frequently told that their pain is psychosomatic
instead of biological, when that is in fact often not the case.
II. Historical Foundations of Andronormativity in Healthcare
Gender bias in medicine is built on a foundation of a historical lack of research testing on women that has created a standard of andronormativity and harmful social stereotypes both on behalf of the patient and women in physicians’ roles. Modern medicine is built upon foundational concepts that date back centuries, where the lopsided practices of antiquity are a frequent excuse for the knowledge gaps in treatment for gender diverse patients, yet even though medicine is always evolving as new discoveries break through, it may come as a surprise how often women still find themselves landing in these “gaps”. Historically, research has been primarily conducted on men due to their deemed more constant hormonal state, which is the most obvious origin of the inadequate, andronormative standard in medicine today, and women have been taken less seriously when it comes to expressing symptoms and receiving a correct diagnosis. In “Medical Myths About Gender Roles”, Elinor Cleghorn writes that “prevailing social stereotypes about the way women experience, express, and tolerate pain are not modern phenomena—they have been ingrained across medicine’s history,” . For example, female hysteria, considered to be the “first mental disorder attributed to women” dating back to 1900 BC , is one of the most prominent examples of gender bias throughout history that was formerly a foundation of medical knowledge about women and, where up until Sigmund Freud in the late 1800s attributed hysteria to men as well, was solely attributed to women for anything from chronic pain or depression to clonic seizures. It can well be noted how Brea’s modern journey to a diagnosis was reminiscent of how “hysteria” had been viewed—the pursuit of a treatment for which resembled a wild goose chase—as she recounts being recommended to a neurologist who diagnosed her with conversion disorder—a neurological system disorder categorized by physical and sensory problems without supporting neurologic pathology—because her “gastrointestinal, neurological, and cardiac symptoms were being caused by some distant emotional trauma that [she] could not remember” , which wasn’t the case. Gendered norms have arisen out of this stigma against women’s biological erraticness and exempted them from study, thus fostering the andronormative environment in healthcare women experience today. In Samulowitz’s literature review titled “‘Brave Men’ and ‘Emotional Women’”, she writes that women being compared to men in patient settings is “proof for andronormativity in health care, stressing that men, and health problems more often present in men, tend to be considered as the norm, while women (and other social groups outside the norm) are seen as irregularities” . As a matter of fact, and though terribly recent, according to Mazure and Jones, the year 2015 marked only the 20th anniversary of the first legal requirement in the U.S. to “include women as well as men in clinical trials and analyze results by sex”  ensuring a more gender diverse testing range for clinical research.
III. The Effects of Gender Bias on Women’s Treatment of Pain
Gender bias negatively impacts how women receive treatment for pain and is a social factor that often contributes to the delay in many female patients receiving successful diagnoses for illnesses involving chronic pain. These impacts of gender bias include knowledge gaps in treatment, lack of women in leadership, inadequate symptom management for patients, and can lead to an overall avoidance of medical care by women who have been burned by the system before . The gender role expectations set by society affects both the patient experiencing chronic pain and the healthcare provider tasked with a diagnosis and treatment. According to Samulowitz, “The appearance of women with chronic pain was judged by their doctors. Some women were mistrusted when they looked too good, as in ‘you can’t be sick,’ while others were judged as unreliable if they did not look good enough,” . Unfortunately, these snap judgments can affect the overall treatment plan of a
patient despite their expression that suggests otherwise, where more often “women, compared to men, received less and less effective pain relief, less pain medication with opioids, and more antidepressants and got more mental health referrals,”  because female expression of pain is typically dismissed as a psychosomatic issue rather than biological, and thus is the reason why women are more frequently misdiagnosed with mental health disorders than men as well . The result of this discrimination of women in healthcare is misdiagnosis, delayed treatment, and general psychological harm because women are being told that their pain isn’t what they feel based on how a physician can overcome seeing the societal expectation set upon the gender of his patient. According to a 2020 study referenced by Leonard, “women with moderate hemophilia receive a diagnosis 6.5 months later than men, on average”, and the findings with hemophilia—a bleeding disorder—are just an example of the disproportionate care received by women when compared to that of men. This evidence perpetuates that “the concept of andronormativity implies that men and masculinity dominate health care to such an extent that women and femininity become invisible,”  especially when women are diagnosed in female-dominated conditions that lie outside the male-dominated research norm.
IV. Progress Towards Erasing Gender Bias in Healthcare
Since the 1960’s, progress has been made for women in terms of erasing the stigma surrounding how gendered norms and accounting for the lack of gender diversity in foundational medicine. As written by Cleghorn, “It is well past time for medicine’s checkered past to give way to a future where the fabric of women’s experience is recognized and respected in its entirety,” , and new forms of study are being taken on as the standard to increase gender diversity and reduce discrimination in healthcare settings. The Gender Role Expectations of Pain Questionnaire, also known as GREP, has been developed in order to “assess gender-related stereotypic attributions of pain-sensitivity, endurance, and willingness to report pain” , and is helping researchers understand how stereotypes affect the response of healthcare providers to presentation of pain and patient’s gauging of their own pain level due to the societal pressure of stereotype
threat; Wesolowicz writes that the “GREP questionnaire is sensitive to gender-related stereotypic views among health care providers and could be used in future work to examine mechanisms of gender and provider differences in pain assessment and treatment” . Because bias has been so steeped in our society’s history and views on stereotypical behavior attributed to gender, increasing education and awareness surrounding gender discrimination for the public will be key to erasing this stigma. “Awareness about gendered norms is important,” writes Samulowitz, “both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the needs of all patients, men and women,” . What follows with this acceptance and increased gender diversity in research is the institution of equitable treatment guidelines for patients across the gender spectrum and, more socially, workplaces, like healthcare institutions, being held accountable for discriminatory behavior .
Bias in healthcare affects women and gender minorities primarily, yet it is everyone’s problem, and inequity in treatment for centuries has led to the marginalization of women and millions of misdiagnoses, delays in proper treatment, and the perpetuation of gender-related stereotypes. The systematic andronormativity of clinical research throughout history, which has barred female hormones as too erratic to be studied and resulted in the “myth that women are too biologically erratic to be useful or valuable,” , and the comparison of women and gender minorities as “irregularities” to men’s measured standard of “normalcy”  is a form of this discrimination in that genders who need to be studied distinctly are not receiving an unbiased form of care. Though deep rooted, this issue is being brought to light with the passing of recent laws requiring diversity in gender testing, which is promising to combat stereotypes on the perception of pain and the female body as well as upset the system of andronormativity. Going forward, progress towards gender equality in healthcare can be made through increasing public education and awareness as well as instituting equitable treatment care guidelines in light of the interpretation of research using GREP .