Handbook of Clinical Gender Medicine. Группа авторов

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Paula R. DeCola, RN, MSc	Justine M. Schober, MD, FAAP
Pfizer Inc.	Department of Urology
New York, N.Y., USA	UPMC Hamot
	Erie, Pa., USA

      Social and Biological Determinants in Health and Disease

      Schenck-Gustafsson K, DeCola PR, Pfaff DW, Pisetsky DS (eds): Handbook of Clinical Gender Medicine.

       Basel, Karger, 2012, pp 10–17

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Gender Effects on Health and Healthcare

      Paula R. DeCola

      Pfizer Inc., New York, N.Y., USA

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      Abstract

      With the advent of gender medicine there is the recognition that differences exist between and among men and women in relation to their health due to the interplay of biologically determined and socially derived elements. This has an impact on preventive, curative, and rehabilitative aspects of health and most body systems. The intent is to explore gender-based differences as well as disparities and their effect on health and health care.

      Copyright © 2012 S. Karger AG, Basel

      Defining Terms and Measurement

      Gender-based medicine encompasses sex differences (genetic, biological, and phenotypic) but goes beyond these to include the broader social, cultural, and normative factors that affect health. Its roots are partly embedded in the women’s health movement of the 1970s, since through the recognition of women’s health came the acknowledgement of gender differences. However, gender medicine is not women’s health and it is it not binary. It extends past the health of women to create new prototypes of male health, as well as to encompass the biological and social aspects of lesbian, gay, bisexual, transgender, and intersex (LGBT) people.

      As with gender medicine, the working definition of disparities extends past a simple one that only accounts for an identified difference between two groups to subsume the idea of social justice. The term is used in keeping with the World Health Organization’s perspective that notes that disparities include a difference between two groups that is viewed as being unfair and unjust, as well as being both unnecessary and avoidable. Further, when determining disparities, equity and not equality needs to be considered through the assessment of need as well as of outcomes, since equal treatment may in fact perpetuate a disparity.

      The Research Void

      As noted by Marianne Legato, a leader in gender medicine, women are not little men, and all men are not alike. In fact, there is growing recognition that biomedical and clinical research has focused on males as a relatively heterogonous group. It has, in large measure, ignored women with the exception of reproduction, ignored LGBT populations with the exception of sexually transmitted diseases, and ignored other minorities and largely concentrated research efforts within high-income countries.

      In the 1990s, in response to the paucity of research on women, a number of jurisdictions established requirements that sex be considered in study designs in order for grant requests to be eligible for governmental funding. Requirements along these lines can be found in diverse counties such as the USA, South Africa, and Australia. However, no requirement or incentive exists that promotes research for other key groups such as LGBT populations or that requires sex and gender to be considered in the composition of ethic committees or in the review of research proposals. This oversight points to a potential root cause for certain health disparities that undoubtedly have health and healthcare system equity implications.

      Healthcare Utilization

Across the healthcare landscape we see different utilization rates, as well as different barriers and enablers to healthcare access. For example, women in high-income countries are more likely to engage in preventative health activities than are men. They are also more likely to seek treatment for most diseases and to do so early in the course of an illness [1]. In contrast, women within emerging economies, such as those of Ghana and India, have been shown to utilize health systems less than men during their lifespan due to restrictive barriers such as childcare duties and care giving obligations, as well as service cost [2, 3]. Irrespective of country of origin, women in general are less likely to perceive their overall cardiac risk level and therefore are less likely to attribute their symptoms to a possible cardiac related health issue [4].

Men’s lower healthcare utilization rates in high-income countries are linked to the trend that they are fulltime workers, work longer hours, and have less flexible schedules than women do [1, 5]. Additionally, the presence of long wait times (more than 1 week) for a routine care appointment is a strong negative predictor of men accessing the health system within the USA [1]. Although variation may exist across countries, a study conducted in Denmark shows that working-age men have higher rates of hospitalization and mortality than their female counterparts [6]. This is attributed to lower rates of healthcare practitioner contact [6].

Available information from both the USA and Canada provides insights with respect to the LGBT population’s utilization of healthcare systems. Lesbians and gay men are less likely to seek preventive care, such as cancer-screening services, and to have poorer health maintenance behaviors than the general population [1, 7, 8]. This disparity is thought to be attributable to stigma, healthcare professionals’ perceived biases, lack of clinical and cultural knowledge, and lack of gender-sensitive care [1, 7, 8].

      Lesbians are also less likely to have health insurance, to see a healthcare practitioner, or to have a consistent source of care [1, 7, 8]. СКАЧАТЬ