Women and Research – Break The Bias

Disclaimer: this text is written from the perspective of a cisgender woman, who’s learning to be more mindful and inclusive of genders beyond male and female.

There is no better occasion to write about women, research, and bias than on International Women’s Day and during Women’s History Month. I‘m a woman working in STEM (Science, Technology, Engineering and Medicine), and I have a confession to make: during my studies in sciences, I believed that current research was done with equity for male and female health issues, that health guidelines were all designed to account for sex-related differences, and that it was obvious that male and female biology don’t always work the same. Well, that’s not always the case. And that realization shook my confidence in what I thought I knew.

Interesting fact: “of the ten drugs withdrawn from the market between 1997 and 2001, eight posed greater health risks for women than for men.” (Sugimoto et al, 2019)

While 21st century research has hugely improved and the situation isn’t so grim for women’s health as compared to previous centuries, we need to improve further. We need to raise awareness about bias in research concerning women (and non-male genders!); we need more people to feel concerned and curious to understand what are considered as facts based on current evidence. (Note that this is exactly how research is supposed to work: we draw conclusions from a set of results, until new results disprove, confirm, or nuance the conclusions.)

At Santé Cannabis, a network of clinics dedicated to facilitating the access to medical cannabis treatments, medical-cannabis-related education, and global patient care, we’re most sensitive to knowledge gaps. Our dedicated research area is, of course, medical cannabis, but more than half of our patient population is female (technically, 64.9 % are assigned female sex at birth). Several health issues for which patients consult our clinic affect women more than men. Being a team powered and led by a majority of women, we feel concerned about how much we don’t know about several of those health issues and the sex-related differences in the effects of cannabis.

Lack of Sex-Related Data Analysis

Being aware of the knowledge gap on medical cannabis, Santé Cannabis leads an observational study collecting patient data to help better understand this treatment. However, we realized a while ago that we were overlooking a crucial element of analysis: sex-related analysis. We previously report results pooling male and female results, which causes an important bias. Also, we previously didn’t collect patient gender, which is important both for patient care and research purposes (more on that topic later).

Does medical cannabis work the same for our female patients as compared to our male ones (referring to their assigned sex at birth)? We can’t say for sure until we analyzed the question.

Unfortunately, sex-related analysis is commonly overlooked and under-reported in current research, (Welsh et al, 2017) and journals with high impact factors (like Sciences, Nature) may contribute to the problem: “Papers with sex-related reporting are more likely to appear in lower-impact journals than are those without sex-related reporting, even when controlling for specialty of publication.” (Sugimoto et al, 2019)

One can’t help but wonder why; is it a lack of consideration for the biological difference between sexes, or do researchers avoid writing their sex-related results because they didn’t find any significant difference? Even if there is no difference between sexes, no one can presume that a drug or a therapy works as well in men and women, for example, unless that result is captured and published.

It’s hopeful that women in research are taking the matter into their hands and do better reporting; indeed, published articles with women as first or last author are more likely to report sex-related results. (Sugimoto et al, 2019) This recent review article (Wright et al, 2020) is an excellent example with a well-researched section discussing sex-related differences concerning anxiety and cannabinoids.

Misogyny in Research

Can some research be so deeply biased that it’s plainly misogynistic?

According to this article (Merone et al, 2022), the answer is yes. By their definition, misogynistic research uses female subjective beauty as an indicator of health but doesn’t measure health or has no clinical practice application.

Can you imagine a paper (Vercellini et al, 2013) grading the looks of patients with and without endometriosis (with breast to under breast ratio)? Only Caucasians were selected into this study, and it excluded women with children, acquired physical defects (like scars), visible piercing, tattoo, dental braces or dyed hair! The article was retracted in 2020, seven years after its publication. (The Guardian)

One can also wonder about the usefulness of some study designs, like in this study (Pietruski et al, 2019) on breast attractiveness and symmetry, determined by where the gaze of observers spent more time. The authors “do not know how the visual pattern parameters translate on a subjective assessment of breast attractiveness”.

Some hypotheses are plainly offensive; this study (Gray and Boothroyd, 2012) made the hypothesis that femininity, attractiveness, and positive mood in young women would mean less minor health issues (cold, stomach issues, infections). Authors made the “assumption that aspects of facial appearance signal mate quality”. The study based the health of the women on self-reported health issues, which is subject to recall bias, and didn’t collect socioeconomic status as a potential confounding variable.

Misogyny in research and medical fields highly impact women’s health; some women have experienced healthcare professionals dismissing their health problems or their pain. A female cardiologist, Dr. Bernadette Healy, coined a term for that deeply ingrained bias: the Yentl syndrome. In this medical context, the term means that for a woman to be taken seriously about her illness, she needs to prove she’s as ill as a man would be. This syndrome, along with the research gap on women’s health issues, delays adequate testing and treatment for female patients. (Mertz, 2011)

On the bright side, blatant misogyny isn’t commonplace in research, and the previous examples are a reminder to keep a watchful eye for bias against women. We must also celebrate the good research done for women, like these publications advancing the collective knowledge about the impact of the menstrual cycle on pain (Hellström and Anderberg, 2003) (Bartley and Rhudy, 2013).

Beyond the Binary Model

Sex refers to the biological, physiological and genetic processes in individuals, and more than male and female sexes exist. Researchers may find it very convenient to place everything in well-defined boxes; however, it’s less convenient for real humans who want to know how research impacts them in real life and when things don’t fit into said boxes. If we consider sex as a spectrum, with female and male on opposite ends, the in-between space is for intersex. Intersex persons are born with characteristics that don’t fit into the male or female typical definitions. (United Nations)

Gender “is each person’s internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, or anywhere along the gender spectrum”. (Justice Canada) Gender also refers to “roles, relationships, behaviours, relative power, and other traits” socially assigned to specific genders (like male and female). (Welsh et al, 2017)

The current medical field considers male (or man) as the model on which research is done and guidelines are built. (Merone et al, 2022) This male centrism is problematic as it disserves all people who aren’t male or men, as well as those who get misgendered.

It’s shocking how even today, people from the LGBTQ2+ community face barriers to access healthcare, coming from lack of education for healthcare professionals, historical oppression, structural injustice (like homelessness) – to name only these. (Schreiber et al, 2021)

It’s urgent to pay more attention to LGBTQ2 + individuals in clinical guideline development and, most importantly, in how health care is delivered. As a medical clinic, we want to be a safe space for all patients and have been assessing how we deliver patient care. However, the current standard of care is only standard for people that are binary (self-identifying as either man or woman), heterosexual, and cisgendered (identifying with the same gender as the sex assigned at birth).

One important action for more inclusive care is to improve communication with patients. A simple change that we’re currently working on implementing is asking for patient pronouns and preferred name. Such a change can go a long way in showing respect for everyone, as incorrectly labelling someone based on assumptions can be hurtful. There are also further simple, uncomplicated changes that any clinic can implement to be more inclusive.

At Santé Cannabis, we’re not perfect, but we’re working hard to always improve. As part of our patient advocacy mission, we raise awareness about research gaps impacting patient safety and care, including gaps on health conditions that predominantly affect women. As part of our research work, we’re committed to better collect and analyze data, with more sex and gender data reporting. As part of our dedication to patient care, we created a diversity and inclusion committee and started concrete actions toward a safer patient space. We hope that our diversity and inclusion statement adequately translates our intention:

At Santé Cannabis, our community is made up of patients, personnel and partners. We honour diversity by creating a safe space for every person to share their lived experiences. We welcome everyone and listen to different opinions, beliefs and ideas as we strive to continually learn what it means to be empathetic and active leaders of accessibility.

Author: Charlotte Bastin