"Gender medicine is not a lifestyle issue – it's clinically relevant"

What do you understand by "gender medicine"?

Gender medicine is often misunderstood. Many people think of women's health or possibly LGBTIQ issues. In fact, it's about factoring biological and social differences – sex and gender in other words – into diagnostics, treatment and research. These have an effect on how diseases develop, what symptoms occur and how effective treatments are.

How do sex-specific factors affect diagnoses?

Heart attacks are a good example. These are classically described as a stabbing chest pain that radiates outwards into the left arm. However, women often experience symptoms such as backache, nausea or shortness of breath. Since these are not regarded as "typical", heart attacks in women are more likely to be overlooked or misinterpreted as panic attacks – often with fatal consequences.

An example of a condition where men are at a disadvantage is osteoporosis, because it's regarded as a "women's disease". But men get it too and it often goes unnoticed.

Why do treatments have different effects depending on sex?

The physiological and biological features of men and women have a major impact on how diseases develop and what effect treatments have. For example, women have a more active immune system. That makes them more susceptible to autoimmune diseases, but often more resistant to cancer. In terms of treatment, the problem is that the male body is generally regarded as the norm in medicine, while the female body is a divergence. Men and women metabolise medicines differently, with many substances remaining in women’s bodies longer. This results in more side effects than in men.

What role do social considerations play?

They affect the way patients communicate symptoms, how professionals interpret them and the treatment strategy that is ultimately chosen. In women, symptoms such as stomach problems or exhaustion often tend to be first attributed to psychological causes, whereas in men they tend to be investigated. Women also tend to push their own health problems into the background because they have to look after their family.

What differences are there in terms of the incidence of cancer?

Overall, cancer occurs more often in men. However, certain types of cancer, such as thyroid or gall bladder cancer are more common in women. Women generally have stronger immune systems, which can protect them against cancer to a certain degree. What’s more, oestrogens protect against cancer, particularly before the menopause.

Social considerations also play a role alongside biological factors: On average, men smoke more and drink more alcohol. Women have different health habits and the extent to which (professional) contact with cleaning products or cosmetics affects their risk of cancer is still unclear.

What effect does sex have on cancer diagnoses?

Sex-specific differences have a large effect on diagnoses. For example, bladder cancer is often only recognised in women at a late stage, since symptoms such as blood in the urine are initially misinterpreted as urinary tract infections and treated with antibiotics.

Women are more aware of the risk of skin cancer, so get themselves examined earlier. Melanoma tends to develop on women’s legs, while men tend to get it on the chest and stomach and have themselves examined later, which leads to a poorer prognosis.

How about cancer treatments?

Women's slower metabolism and lower muscle mass means they often get more serious side effects from chemotherapy. Nevertheless, medicines are often administered in standard doses based on body surface area. This can have fatal consequences. For example, I can remember a bladder cancer patient who had to stop chemotherapy before tumour surgery because of severe side effects, which in turn reduced the likelihood of a cure. She died. We might have been able to save her life if we’d had better adapted treatment options.

This is one of many cases that shows that gender medicine is not a passing fad, but can make the difference between life and death. Medicine needs to become more sensitive to sex and gender so that everyone, including men, gets the best possible treatment. Take breast cancer for example. Men account for just one percent of breast cancer cases. They get exactly the same treatment as women, even though there is not enough trial data to justify this.

Why do men and women often receive the same treatments?

Because for a long time, clinical trials were conducted almost entirely with men. Following the thalidomide scandal, there was a desire to protect women, which resulted in them being excluded from trials for decades. They are still under-represented today.

At present, the industry has few incentives to conduct gender-specific research because of the cost and complexity involved. However, instead of funding expensive new trials, it could analyse existing clinical data for gender-specific differences. Often just modifying the dosage would be a major step forwards in reducing side effects. However, age, ethnic background and social situation also need greater consideration. For example, elderly people are often excluded, even though they frequently need medicines, and metabolism changes at an advanced age, which impacts the effects and side effects they experience. Ethnic differences also play a role. For example, Asian patients often respond differently to certain medicines than European patients. In addition, socio-economically disadvantaged groups are less commonly represented in trials. Greater diversity in medical research with an intersectional perspective would help encourage greater equity in medicine.

Is diversity considered to a greater extent these days?

There has been progress. Guidelines such as the Sex and Gender Equity in Research (SAGER) guidelines require systematic consideration of gender-specific differences in medical research. Scientific journals are also increasingly demanding gender-specific data in trials. There is growing awareness of gender medicine, particularly among the younger generation, but structural barriers often prevent women from rising to leadership positions, even though the vast majority of research into gender differences is done by them. For that reason, it will be difficult to achieve genuine progress in implementing gender-sensitive medicine until there are more women in key positions.

Attitudes are also changing as regards animal testing and preclinical research. For a long time preclinical trials only used male animals; nowadays they are required to include females.

What does the future look like for gender medicine?

Gender medicine is being widely discussed in science. However, there is political resistance, particularly in the USA, where research projects involving vulnerable groups within society or sex-specific issues are being neglected since Trump returned to power. Simply using certain terms can lead to funding money being cancelled or research applications going unapproved.

If we really want to drive forward precision medicine, we cannot let ourselves be discouraged by ideological resistance, but must systematically advocate inclusive, evidence-based medicine. Dropping diversity goals from clinical research could set medicinal product development back a long way. While knowledge about gender-specific differences exists, real-world implementation remains a challenge. We need to generate more data that will facilitate tangible change. The crucial thing would be to analyse women and men as separate populations.

Medicines dosage is an important area of innovation. Factors such as sex, body size and weight should be considered during the early stages of trials. This would not only increase safety and efficacy, but pave the way for more individualised treatments.

What do you expect from Swissmedic in terms of gender medicine?

I see an important role for Swissmedic. Firstly, patient safety has to be paramount, secondly there needs to be openness to innovation, even if the available data pool is not always perfect.

Gender medicine is an area where Swissmedic can help set the direction, just as it is currently doing by assessing author- isation-related trial data separately by sex and, where data are missing, requesting additional analyses. That way we can better understand the differences in effect and side effects and can take them on board. If we take greater account of sex-specific differences at all levels, from medicine development to authorisation, it is a major opportunity to improve medical care for everyone.

An informed and concise interview with PD Dr Berna Özdemir on the relevance of gender medicine.