The gender gap: new challenges in women's health☆

Gender differences in health 

Research has shown that gender differences in health and disease are significant. Coronary heart disease presents in women 10 to 15 years later than it does in men. Men are more likely to present with myocardial infarction as a manifestation of the disease, but women are more likely to die within 1 year of having an initial recognized myocardial infarction. Women are more likely to have co-morbidities such as congestive heart failure, hypertension, and diabetes. Women have fewer diagnostic procedures than men and are less likely to be given effective interventions such as aspirin, β-blockers, and thrombolytic agents (Table 1). .

Table 1. Women's Health: New Challenges

	Key Issues
	Differences in health and disease exist between males and females that cannot be attributed to hormones.
	Understanding the basic biology for these differences will improve diagnosis and treatment of those disorders that affect women differently than men.
	Disparities in health status and health outcomes exist among diverse populations of women with poorer health among minority women, with few exceptions, across a range of illnesses.
	Recent research indicates that along with level of education, individual behavior, access to care, environmental factors, income and possession of insurance, differences in the quality of health care is a contributing factor in disparities in health status and health outcomes.
	Women are living longer but often with decreased function.
	Factors such as gender, education, economic status, race and ethnicity, all are predictors of health status, but quality of life, as one grows older, is more than absence of disease and, aging successfully, requires more than being healthy.

Blood pressure is higher in men than in women of comparable ages until menopause. Then blood pressure in women increases to levels higher than those in men. Women live significantly longer after colon cancer resection than men with comparable disease. Women smokers are more likely to develop lung cancer than men, taking into account baseline exposure, body weight, and body mass index. Women are 2.7 times more likely to develop autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, and lupus.

Men and women respond differently to medications. Women are at higher risk for adverse reactions to drugs as diverse as antihistamines and antibiotics. Antiarrhythmic drugs can induce a potentially lethal cardiac rhythm, torsades de pointe. Hypokalemia, hypomagnesemia, bradycardia, and QT interval prolongation that may be affected by the menstrual cycle increase susceptibility to this event.

Women generally perform articulatory tasks and fine motor tasks more quickly than males. Men demonstrate an advantage in visual–spatial ability. Certain classes of opioid analgesics are more effective in women than men.

The US Institute of Medicine (IOM) issued a report, “Exploring the Biological Contributions to Human Health: Does Sex Matter?” The committee concluded that sex does matter. It found that differences in the basic biochemistries of males and females on a cellular level can affect health, and that these exist across the life span. It also reported that differences in metabolism and susceptibility to pharmacologic agents exist. Additionally, there are behavioral and cognitive differences between males and females.

Closing the gaps 

In 1999, of the nearly 140 million women living in the United States, women of racial and ethnic minorities comprised 39.6 million (28.3%) including African-American (12.5%); Hispanic (11.2%); Asian American/Pacific Islander (3.8%); and American Indian/Alaska Native (0.7%). Disparities in health status and health outcomes, with poorer health among minority populations (with few exceptions), exist across a range of illnesses.

Cardiovascular disease is the leading cause of death for African-American, Hispanic, American Indian/Alaska Native, and white women and is the second leading cause for Asian American women. African-American women have the highest mortality rate from heart disease (147.6 per 100,000). In contrast, the mortality rate from heart disease for white, non-Hispanic women is 90.4 per 100,000; for Hispanic women, 64.7; for American Indian/Alaskan Native women 92.8; and for Asian American/Pacific Islander 49.3. Black women are less likely than other women to receive life-saving therapies for heart attacks. They are least likely to receive reperfusion therapy (44%), followed by black men (50%), white women (56%), and white men (59%). Black women are less likely than others to be referred for cardiac catheterization.

Cancer is the second leading cause of death for women of color, except for Asian American/Pacific Islander women, for whom it is the leading cause of death. Lung cancer, the leading cause of cancer deaths for women, is on the rise. For women of color, the rate is highest among American Indian/Alaskan Native women, 58 deaths per 100,000, and the lowest among Asian American/Pacific Islander women, 11.5 and 8.9, respectively. African-American women have the highest rate of death from breast cancer, 31 per 100,000, even though the incidence of breast cancer among African-American women is lower than that of white women.

Diabetes is more common among women of color than among Caucasian women. In 1997, diabetes was the fourth leading cause of death for African-American, American Indian/Alaska Native, and Hispanic women. It is most common among American Indian/Alaska Native women; 41% of older women in this population have diabetes. Among some subgroups of this population, the incidence is even higher. Additionally, the adverse outcomes associated with diabetes among some minorities are far worse than that of others. When compared with white women with diabetes (15%), African-American women with diabetes (25%) are more likely to develop end-stage renal disease, be blinded, have limbs amputated, and die of their disease.

Maternal mortality and infant mortality are added examples of marked disparities in health outcomes. Maternal mortality and infant mortality among African-American women are 4 and 2.5 times greater, respectively, than the national average. African-American women have the highest rate of low birthweight (<2,500 g) births than any other racial or ethnic group.

The death rate due to cerebrovascular disease—primarily strokes—among black women is nearly twice that of all other women. HIV/AIDS, other sexually transmitted diseases, and co-morbidities, likewise disproportionately affect women of color.

The IOM's report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (see Table 2) . concluded that “racial and ethnic minorities tend to receive a lower quality and intensity of health care than non-minorities, even when access-related factors, such as patients' insurance status and income is controlled.” The committee recommended legal, regulatory, and policy changes, health systems interventions, programs to enhance patient education and empowerment, integration of cross-cultural studies into the education of health care professionals, and improved data collation.

Table 2. Summary of Findings, IOM Report on Racial and Ethnic Disparities in Medical Treatment

	1-1: Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.
	2-1: Racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life.
	3-1: Many sources—including health systems, healthcare providers, patients, and utilization managers—may contribute to racial and ethnic disparities in healthcare.
	4-1: Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. While indirect evidence from several lines of research supports this statement, a greater understanding of the prevalence and influence of these processes is needed and should be sought through research.
	4-2: A small number of studies suggest that racial and ethnic minority patients are more likely than white patients to refuse treatment. These studies find that differences in refusal rates are generally small and that minority patient refusal does not fully explain healthcare disparities.

Reprinted with permission from Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002) by the National Academy of Sciences. Courtesy of the National Academies Press, Washington, DC.

An aging population 

In the early 1900s, roughly one of every 25 persons was over age 65. By 1980, the ratio was one in eight. In the early 2000s, it will be one in every five. Today, 34 million Americans are 65 or older. Three out of five are women. By age 85, women outnumber men two to one.

Fifty percent of female Medicare beneficiaries have incomes of less than $10,000. Forty-two percent have less than 12 years of education. Some 24% report fair or poor health; 29% have three or more chronic conditions.

Of the 34.5 million Medicare beneficiaries over age 65, 19.4 million (56%) are women, and among those 85 and older, roughly 70% are women. The mean annual income for women 65 years and older in 1999 was $15,615; for men it was $29,171. The proportion of female Medicare beneficiaries, aged 65–84 years, with incomes below $10,000 was 26%, and over age 85, it was 44%, while in men, the numbers were 14% and 26%, respectively. Twenty-seven percent of women on Medicare have no prescription drug coverage and women on Medicare spend a greater portion of their incomes on health care than men (22% vs 17%, respectively). Women without drug coverage fill seven fewer prescriptions, on average, than do women with coverage, placing them at increased risk for complications of their health problems.

Given their longer lifespan, women are more likely than men to have multiple health problems. Although women live, on average, 7 more years than men, they live more of those years while functionally disabled. Major contributors are stroke, depression, hip fracture, osteoarthritis, and heart disease. Of the 10.6 million Medicare beneficiaries with long-term care needs (defined as one or more limitations in activities of daily living), 61% are women. Of the 1.5 million nursing home residents aged 65 and older, 75% are women, and, of the 2.4 million home healthcare users, 67% are women.

Poor health is not a foregone consequence of aging, yet, despite recognition of the importance of preventive care and healthy habits in improving quality of life in later years, women and their physicians miss opportunities to promote good health. Preventive healthcare rates have changed very little over the past 10 years. Additionally, disparities exist in screening rates across income and education levels. Uninsured women are less likely to visit a physician on a regular basis and are less likely to have preventive care screening procedures.

The majority of women do not receive counseling from their physicians on a number of health issues. Although heart disease is the leading cause of death for women, only 34% of women report that their physicians discuss heart health with them. Fewer than 50% report that their doctors discuss the importance of exercise, diet and weight, and calcium intake. Less than a third reported discussions about smoking and drugs and alcohol. Only 8% report conversations about safety or violence in their homes. Although colon cancer is the third leading cause of cancer deaths for women, of women 50 years and older, only about half reported ever receiving sigmoidoscopy. Overweight and obesity elevate the risks of illness from heart disease, diabetes, hypertension, osteoarthritis, and other musculoskeletal problems. Regular exercise lessens these risks. In 2000, 39% of women reported no non-work-related physical activity. Among the elderly, musculoskeletal strength and exercise are important in preventing falls, yet, among non-institutionalized women over 75, 50% report no physical activity during leisure time.

Factors such as gender, education, economic status, race, and ethnicity all are predictors of health status, but quality of life as one grows older is more than the absence of disease, and aging successfully requires more than being healthy. Research is showing that possessing self-respect, having more control over one's life, enjoying quality connections with others, having purpose in life, and possessing a certain degree of resilience, are key ingredients to aging successfully. Some of these are not acquired solely by one's own accord, nor can they be applied universally, but there is evidence that they are important ingredients for successful aging. Supportive family and friends, a life without violence, recognizable achievements, and appreciation for who one is and what one does are important ingredients.

An individual has to have financial security to have autonomy. Without this, one is dependent on family members. Purpose in life, a critical feature of wellness, requires a realization of one's potential and the ability to see life as meaningful. Possessing a certain amount of resilience gives one the ability to spring back from adversity, which occurs so commonly among older individuals, and transforms adversity into an opportunity to learn. Although not entirely clear, research suggests there may be a link between social well-being, happiness, and better function, and reduced mortality. Understanding what constitutes successful aging and how it is achieved is a new area for research.

Conclusion 

Much of the improvement in women's health during the 1900s can be attributed to research, education, and policy changes in reproductive health. While there is a need for continued research and improvement in this area, new challenges must be addressed. These include: the widespread disorders that affect women differently from men; the relatively poor health of minority women; and the specific needs of a growing population of elderly women.

Research and education, and where warranted, policy changes, must be directed toward existing, as well as newly emerging, health concerns, if there is to be continued improvement in the health of women.1, 2, 3, 4, 5, 6