#173 Dr Alyson McGregor: Author of Sex Matters

Dr Alyson McGregor

We are delighted to speak with Dr Alyson McGregor, a women’s health pioneer who has brought the concept of sex differences in the delivery of acute medical care to the national and international stage. She is also the author of: Sex Matters: How Male-Centric Medicine Endangers Women's Health and What We Can Do About It.

Sex Matters represents a landmark moment in acknowledging the importance of understanding female bodies in all aspects of health research, treatment and medicine development. Reviewers for the book state: “Sex Matters tackles one of the most urgent, yet unspoken issues facing women’s health care today: all models of medical research and practice are based on male-centric models that ignore the unique biological and emotional differences between men and women – an omission that endangers women’s lives.

Listen Here (transcript below):

Dr McGregor is an Associate Professor of Emergency Medicine at The Warren Alpert Medical School of Brown University and the Co-Founder and Director for the Division of Sex and Gender in Emergency Medicine (SGEM) at Brown University’s Department of Emergency Medicine. Dr. McGregor is also a Co-Founder for the US national organization Sex and Gender Women’s Health Collaborative.

You can read more about Dr Alyson McGregor’s pioneering work to shed light on sex differences and the importance of acknowledging women in medical research on her website, follow her on social media and watch Dr McGregor’s TedTalk titled “Why medicine often has dangerous side effects for women,” which has almost 2 million views.

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Transcript:

Raquel Rosario Sanchez from FiLiA in conversation with Alyson McGregor

Hello everyone. Welcome to the FiLiA podcast.

My name is Raquel Rosario Sanchez, and I am the spokeswoman for FiLiA.

Today we are delighted to speak with Dr Alyson McGregor. She's an Associate Professor of Emergency Medicine at the Warren Alpert Medical School of Brown University in the United States.

She's the co-founder and director of the Division of Sex and Gender in Emergency Medicine at Brown’s University's Department of Emergency Medicine. Dr McGregor is also the co-founder of the national organisation, Sex and Gender Women's Health Collaborative. Dr McGregor's is a women's health pioneer who has brought the concept of sex and gender differences in the delivery of acute medical care to the national and international stage.

She's also the author of Sex Matters: How Male-Centric Medicine Endangers Women's Health and What We Can Do About It. So, first of all, thank you so much for this podcast Alyson.

Alyson: Raquel, thank you so much for this invitation. And I look forward to this discussion and I hope that your audience can learn about some of these factors as well.

Raquel: Let's start from the very beginning.

You talked about how once you had decided to go into medicine, you were very interested in women's health. So people would ask you, well, what do you want to do? What's your specialty? And you would say, well, I want to do women's health. And people just assume that you meant reproductive issues, you know, in pelvic exams.

You write that there is far more to women's health and pelvic exams and mammography, women are different in all sorts of ways. So tell us about how you realised that there is a lot more to women's health than that.

Alyson:  So after I was finished with medical school and I was in my emergency medicine residency, which is how things go in the United States.

And so it was a four-year residency learning how to be an emergency medicine physician. I was nearing the end of that and getting ready to graduate which means I could be a practicing physician. And I wanted to stay at Brown University and start working on some research. And that's when I started to look for a mentor to help me sort of get started in research.

I had some ideas for some projects. And when I decided to focus on women's health, I found that when I was looking for mentors and I said, I'm looking to do some research projects on women's health. They thought that I meant obstetrics and gynaecology, as you mentioned.

And so for me, I really felt as though my upbringing towards… [was] a nod towards feminism. I was very appreciative of the work that the women's revolution had done for equal rights for women. And I followed that all along. And so by wanting to focus on women's health, that was my way of saying, okay, let's try to increase and improve the health of women.

But then when I realised that people thought I meant obstetrics and gynaecology, that's when I really dove in first, I thought this can't be the only thing that people assume encompasses women's health. I see women have heart attacks. I see women have strokes. I see women with infections and all of these conditions, chronic pain. So I see all of these women in the emergency department with many, many conditions, not related to their reproductive organs.

This was about the time that the cardiovascular research was showcasing, that women might present differently when having a heart attack than men. And so I thought, well, that's really interesting. Maybe that's at the crux of this… is why do women present with different symptoms? Is it because they have different ways of having cardiovascular disease? And so I started to look at that literature and realised that the major cardiovascular clinical trials had only enrolled men. And so I thought, that's probably key to this.

And so I realised that most of our clinical trials, most of our health research, most of our understanding of drugs and their efficacy and all of our entire medical framework was really built upon the knowledge base of men, mostly white men, mostly white men in their twenties and thirties.

And we use this knowledge to apply to everybody. So during my medical training, I was learning medical knowledge based on men and expected to apply that to women. So that's really what started this passion for me.

Raquel: You call this the male-centric model of medicine. And I have a question. When did it become a more established understanding that well, actually, no, we need to analyse women as different from men on a chromosome level from the very beginning. When did this became more acknowledged within the medical community?

Alyson: The more and more research that was being done that looked at this, started to creep in, and it was shocking for researchers and physicians alike.

In 1973… the National Research Act, which really labelled women as protected subjects which eliminated them from being enrolled into clinical trials. And it wasn't until the women's revolution movement in around 1993, where they took that back and they said, oh, we probably didn't do the right thing. We thought we were protecting women, but we actually did them a disservice because we haven't studied their unique bodies and physiology.

And so that was when they tried to say let's enrol women. But our basic, our understanding, our major clinical trials, the animals that were being used and preclinical studies were all still male models.

And so it was difficult to just all of a sudden sprinkle a few women and call it that it was purposeful. It didn't really align us with understanding women's unique physiology. So by the time the NIH in America, our major funding body, in about 2015, 2016, they said that we need to make sure that women are included in all stages of clinical trials.

So preclinical and cellular studies and animal studies and all the phases of clinical trials. And because of that hallmark rule, it really set the stage for lots of researchers to study this and exponentially the data on the differences between men and women are just coming to light. It's really amazing.

I feel as though that this was such a detriment to many, many women along the way.

Raquel: It really does feel like a transformative moment in medicine. You're right. Every cell in a human body contains sex chromosomes. These chromosomes in turn influence every biological, chemical, sensory, and psychological function performed by that body.

Most cells both produce and respond to sex hormones, such as oestrogen, progestin, testosterone, and androgens, and the functionality of each cell is affected in both subtle and overt ways by its relationship to this hormone. So we're getting a holistic sort of revamping of the medical establishment’s way of understanding half the world's population.

So just to like ground a little bit, so our audience understands what it is that we're talking about. You put some examples of how actually women's bodies need to be understood as different and you write for example, men and women have markedly different responses and reactions to pain.

Women have both a lower threshold for pain and a lower pain tolerance, meaning that they are more likely to perceive and report a lower level of discomfort as pain than men, despite the equal degree of stimulation. However, the more vocal women become about their pain, the more likely their providers are to tune them out and prescribe either inadequate, or inappropriate pain relief medication.

So this is affecting women all over the world in their everyday lives.

Do you feel like it's a daunting prospect is right to try overturn such a vast problem?

Alyson: I don't anymore. I used to think that. I've been in this field of study for about 15 years now. And when I first started talking with people, they didn't understand the gravity of the situation. They didn't realise that it was a problem. In fact, most people, scientists and the public alike thought we were taking these considerations into account already. So it took a lot to really sort of have that aha moment. And what created that aha moment for lots of scientists and doctors was the fact that the data was showing that this is the case.

And so when you think of something like pain, it's the equaliser in the emergency department. It's the most common symptom/presentation. it's something that we deal with a lot. but when we look at the studies of the differences in thresholds for pain, as you mentioned, there's different things to look at.

So what we're now realising is that the pain pathway from say a burn on your hand, all the way to your spinal cord, to your brain and then you say, ouch, we have learning that that pathway is different between men and women. That to me is just incredible that there are different cells that respond to that, and those cells are involved with the levels of oestrogen and testosterone.

So if you think about that, even the mechanism of signalling that there's some discomfort is different between men and women. Most of our understanding and treatment of pain disorders, were based on the male pattern of telling the brain that there's something painful.

So our entire structure was built on a male pattern, yet, it was only a few years ago that this particular researcher found that there are different cells and there are different pathways. So even something so fundamental like that has affected the way that we treat pain for men and women.

And then we look at bias, there's bias in the system, there's gender bias. So when we say sex, we mean that cellular sex on hormones and all of these really sort of cellular processes related to the DNA. When we think of gender, we think of how someone presents themselves in society. And so if you present yourself as a woman in society, that is something that affects your health and your access to healthcare as well.

So women are constantly seen as exaggerating, as being anxious, partly because women are environmentally and socially acceptable to cry or to have emotions and are more comfortable in expressing their emotions. And what happens is this is been an, also a study that when you have a male physician with a female patient, that male physician will decrease the volume of the female patient’s pain response though, they'll think, oh, women are always complaining of pain or it's probably not that bad. And I have to just kind of notch this down a little bit. And women, when they have a male physician will increase the volume of that pain because they're thinking he's not going to believe me. So I have to really show that I'm serious about this painful condition.

And so there's that constant bias and negotiation that occurs between two genders and then also when you think about the physiologic aspects, it's really astounding.

Raquel: I wonder when you have this conversation, because now you have become very renowned in your field, you have a leadership position in the medical community when it comes to women's health now.

When you have these conversations in the medical community with male doctors, what is that like? Do you encounter resistance or are they open to the possibility that actually maybe we have been really hurting women through the way the medical establishment has ignored women's bodies?

Alyson: It's a great question. And I really have experienced, especially now that when I have these discussions with male scientists, male researchers, male physicians, there is this acceptance of thinking about their education and their understanding of science differently, because for the most part, people go into the medical field for altruistic reasons. They want to help, everybody, they want to help the humans. And so there's that sort of understanding also that the longer that you are in the medical field, the more things evolve, the way that we used to do things 50 years ago, we wouldn't even consider that now.

We never wore gloves. We didn't understand sterile conditions, the need for, you know, anaesthesia during surgery, all of these things we evolve. And so there's this understanding of, oh, I guess that this is just the next level of evolving our understanding of science and so I think that, that there's that piece people hold on to.

Raquel: So there’s a receptive environment now because of the data, because the data is showing we're seeing this across the board with women and it's not, a theory. It's not speculation. There are different ways that women present and react to medicine to pain, to diseases.

Alyson: One of the biggest challenges for physicians is that we have been taught, it's a very extensive long education process and it really never ends. The more you see patients, especially during residency, you are learning by your mentors, you're learning by the attending physicians. You are trying to gain pattern recognition.

What does a heart attack look like? What does a stroke look like? What does someone in pain look like? And so after you know, all of the training, it’s hard to change but you have to realise that you were trained in a male framework. And so that is not going to fit when you have a female patient.

So it is challenging because now we have to, as the science and data keep increasing exponentially, we have to get that information into health professionals education. So that we can teach the new doctors, the new nurses, the new pharmacists, the way of this new evidence in data, and try to really help established physicians to also understand that they need to re-look at the way that they were originally educated.

Raquel: You coined the phrase ‘undiagnosed women's disease’ about the gap of cases that are still unexplained by the medical establishment relating to women. Can you explain a little bit what this term is about?

Alyson: Sure. So I see again, women with all sorts of complaints, that's worth it for them to come into the emergency department.

And what I see are a large amount of diagnoses that really aren't diagnoses. They're just a collection of symptoms. They're just syndromes. So for instance, autoimmune conditions, it's not very well known what's actually causing all of those autoimmune conditions. Like what's the underlying physiology for that for chronic pain disorders, fibromyalgia, irritable, bowel syndrome, all of these sort of things that women can experience and then try to talk to their doctor about.

There's really not a full understanding of studying these particular conditions in women. And so I feel that once we start to look at women as unique and really start to look at why they suffer from all of these chronic pain conditions and these undiagnosed diseases or undiagnosed conditions, we'll be able to understand what's actually going on. So I'm hopeful for the future for this, and I'm hopeful that we can get specific treatments for women.

Raquel: What I find very difficult to comprehend is that a lot of these clinical trials, a lot of these studies, the research has been done in countries like where you are in the United States, for example.

So then from the moment that you, as you mentioned, you know, any clinical trial, like you begin with an idea from the moment that this begins as an idea to the moment that it reaches a woman in a rural community in the global south, you know, that that perhaps the heart attack is not going to present the way that they doctors have been taught it should present, is that decades? It’s such a long trajectory that it really worries me that we're barely beginning to understand the impact of ignoring this sex differences. And by the time this become accepted knowledge in the medical field, then how many women's lives will be lost because of undiagnosed or misdiagnosed conditions.

Alyson: I agree with you. And I think the impact on women is immense. And that's the reason why I wrote my book Sex Matters because we don't have time to waste or wait, really. if you think about it, I was working really in the beginning at adding to the literature, doing research studies to determine if there are important sex differences, thinking that this would be the best way to tackle this problem.

And then I realised that by the time that information comes to light, you know, years go by, as you said. So I really wanted to try to empower women today to be able to at least navigate the healthcare system to the best of their ability that's possible right now. So that's kind of where I want women to understand that they need to really own their personal medical record, like really understand what their problems are listed as, and to make sure that they agree with them, make sure that things don't get copied and pasted. So that way, you know, if you were told you have anxiety of reaction, one time that all of a sudden now you're an anxiety, you fit the criteria for generalised anxiety disorder, which most women do not.

These types of things to empower them, to ask questions, to make sure that they do research and feel comfortable to ask questions of their doctors like, Hey, this medication you just prescribed for me was this studied in women? Is there anything I should know about it specific to me being a woman or should I have a different dose or are there different side effects that I should be concerned about? And I would also encourage, if your doctor is not open to these discussions, they may not know the answer, but just because you asked them, they will probably look it up and then learn something that's new and that they can carry on to their other patients.

And if you don't have that type of relationship with your physician, then I encourage you to look for one that you do.

Raquel: We are taught that the doctor is the authority and they are in an authority position. And sort of you trust that their opinion on these health issues should be accepted, you know? So I think that when we're now thinking about, well, does this make sense to me? Is this what I'm actually feeling? What do I think about this? You know, to, to think about the relationship of doctor and female patient, as a conversation, rather than just assuming that they will know, they will have the best data, they will know the latest research. That really is a shift in how we think about doctor and patient relationship.

Alyson: It is. And it's an important shift. I think that you should really look at your physician as a very, well-educated very well knowledgeable consultant in your healthcare. We don't have that paternalistic relationship with our doctors anymore, that shouldn't be the case. There's just so much to learn.

The amount of medical information that's out there is, is impossible for any one doctor to really keep up with. So I always invite conversations with my patients most of the time, even just asking them: What are you hoping to get out of this visit? maybe it's just that you want to be heard.

Most of the time when I just let these women describe their situation and all that they've had to go through, that alone can be very therapeutic because most of the time, lots of these things are dismissed. So I do think that it's a shift, but I think it's a very healthy one for both the physician and the patient and their relationship.

Raquel: It’s about making the whole system better.

You talk about society and women's health a lot and you mentioned how anxiety has become a go-to diagnosis for women. You talk about how, oftentimes women are dismissed. You say, when providers are unsure what's wrong then science is their default explanation, and the symptoms for anxiety can mimic the symptoms of major diseases, such as heart attack and stroke, as well as other ailments.

So why is it that when a woman comes into her local ED with a racing heart, chest pains and laboured breathing, is she more likely to be given a diagnosis of anxiety than the men with the same situation? Why is a woman who comes in with abdominal pain, more likely to be sent home with antianxiety medication rather than IBS protocols?

You talk a lot about anxiety is the hole medical community has fallen into. It's like, well, these women are presenting with the symptoms. Let's just assume it’s anxiety. How did you begin to notice this pattern?

Alyson: Just working in the emergency department.

It's very, very obvious to me over time. It was just really astounding, because I work with residents and students, and those students and residents are being taught by other physicians as well. So when we would see a patient with, as you described, the shortness of breath and racing heart, and maybe some chest discomfort, they would say, oh, they're listed, they have anxiety. This is probably their anxiety reaction.

And so probably because that patient has been told before that this is their anxiety reaction. And so oftentimes the women patients will say to their doctor, this could be just my anxiety. And as soon as you say that, that can be the sort of anchoring diagnosis that the physician can go on.

But part of the problem is that, especially for heart attacks, we were taught that women don't have heart attacks until they're post-menopausal. So if you are 40, 50, even 35, there's no way that you can have a heart attack if you are a woman. and that's completely false now. Women have different types of heart attacks and they have different symptoms with those different types.

And so we're learning these things now, but you know, the textbooks still say that, a male will be clutching his chest. And so we've just been thinking that men have heart attacks and women don't.  and so I think also as we're learning about how women have disease, that's different from men.

The treatments are, are, need to be different as well. So, without getting too technical, like when you said abdominal pain, most of those time we do a cat scan to look for an anatomical abnormality that we can say that that's where the pain is coming from. And a lot of times that doesn't happen with women because they have gastrointestinal disorders that aren't really figured out or studied, or they have this autoimmune problem that's attacking their digestive system.

And so I think it's just the lack of understanding women's disease processes. And then the lack of teaching this to our healthcare providers.

Raquel: So just to be extra thorough, could you explain to our audience the difference? Cause you talk about six areas that represent a major problem for women's health and one of those is cardiovascular issues.

Could you explain to our audience, what are the difference between heart attack conditions between men and women that you notice in your practice?

Alyson: I noticed that women, even if they're having a classic heart attack, so let's just define what a classic heart attack is. You have blood vessels that provide fresh blood to your muscle, your heart muscles. So you have a large artery and we've looked at that as ooh, that large artery can get clogged and get blocked and so it will no longer bring blood to your heart muscle. And that part of the heart muscle will die because it's not getting blood. That is a heart attack. That is the heart attack that we have been taught. And that is the way that both men and women can have a heart attack, but that type of heart attack is more common in men.

Women don't have just a big blockage there. Women are more likely to have smaller blockages of the smaller vessels. They're more likely to have a tear in their artery, which can cause a heart attack. There are other forms and ways of having heart attack that we haven't appreciated because we’ve studied men.

This is the more common way that men have heart attacks. And so that has been really something that I've noticed a lot, because when you start to now think about these other forms of having heart attacks, we can diagnose these things better for women. And it's not just about realising that there is more than one way, the male way, to have a heart attack. We also have to realise the way that women express themselves. So, you know, if women are having blockages in their smaller arteries, it's not going to be a sudden elephant sitting on their chest. They might feel discomfort and fatigue for weeks, or nausea or shortness of breath and all of these other symptoms that you can sort of relate back to. Oh, this is because this is how it's going on in their bodies.

 It's also just also socially cultural, that women can say that they aren't feeling well and they often do that with emotion. So if a woman comes in saying, I don't feel well because of this, this and this, but they're also happened to be tearful when their heart rate is high and they're hyperventilating, we have to make sure that we understand that that is just a symptom, that is not necessarily the cause for the underlying condition. And so we need to really sort of disconnect an anxiety reaction from the underlying diagnosis.

Raquel: And, and just touching on that point, the anxiety issue, it comes across like we really are pathologising normal reactions in women and assuming that they are anxiety.

So how would you differentiate a woman being concerned or worried about this pain that I have, and what's actually anxiety, something that needs the medical evaluation.

Alyson: I think it's important to make sure that the anxiety as a diagnosis is a diagnosis of exclusion.

For you to have a generalized anxiety disorder, that has very specific requirements that psychiatrists use and treat and it can be very debilitating for men and women. But if you have a sort of a response and anxiety response because you have abdominal pain, now you're anxious and you've had to leave work or leave your family and go into this very foreign fluorescent lights and sirens, you're going to be anxious about that.

 So I think it's very important to say like, okay, let's wait a few minutes. Let's get some tests, let's get some objective data first. Let's get you feeling better and see if we get you feeling better, that the anxiety also gets better.

For instance, something as very as simple as say, I have a man who broke his arm in one examining room and a woman who broke her arm in another examining room, there's probably likelihood that that woman is going to be tearful or anxious, how was she supposed to do all the responsibilities that she does. So what I’ll see is that some of my students and residents and colleagues will then give that woman an anti-anxiety medication and then they'll give the man pain medication. And so what I say is she's probably anxious because she's in pain, that's hurt, a broken arm hurts, let's treat her pain first, and then maybe she'll be less anxious about the fact that she's so in so much pain.

It's those sorts of things that, if you see crying or tearful or anxious woman that could just be a reaction to something that's real going on and so I think just disconnecting those two from objective data is the first step.

Raquel: Yes. It sounds like we're trying to create a quicker fix when some of the symptoms that women are presenting, we need to really put some thought process into it. Well, what is it that I'm seeing? I'm seeing a woman who is really upset. What is she upset about as opposed to just assuming that her being upset is the problem?

You talk about how sometimes women present to the doctors at their practice with symptoms, and sometimes they talk themselves down, getting secure. Is this thing that I'm feeling bad enough for me to go to the doctor or should I just dismiss it?

And we think sometimes we think that maybe the issues that we're dealing with, the medical issues that we're dealing with are not as serious as they actually are, because we doubt ourselves.

So what advice would you have to our audience when it comes to medical issues and the pressure and the socialisation? Women are socialised to try to not make a big fuss about everything because you don't want to seem hysterical.

 What would you advise our audience when it comes to symptoms that are developing where you don't want to be seen us as the complainer?

Alyson: What I've discovered by interviewing some women as well is that they'll go to the emergency department and they don't know what to do.

Do they overly express the fact that they don't feel well and then be seen as someone that's hysterical or do they under express it? But then the doctor might think why are you here if it's not that big of a deal? So it seems like women are the ones that have to negotiate that.

And so what I tell women is to be an advocate and bring someone. So when you bring someone with you, a spouse, a partner, a family, a friend, and that person then can help you sort of advocate for you. So if you don't feel well, it's hard to navigate that system, but if you brought someone with you that says she does have anxiety, but never presents like this. This is something different. I know that there's something wrong. She does have pain sometimes, but never, never like this. I think that that's really important to have at least right now, just to break through some of these barriers and to have a second voice there. I think that that is very helpful for a lot of physicians helpful for a lot of patients.

 And I also like to say that women are intuitive and as intuitive beings, we should really embrace that. And if we feel as though something is wrong, checked out and if we feel as though that when we got checked out, it wasn't satisfying enough then try someone that you do trust.

Oftentimes women are just cycled through specialists because they're like, oh, this can't be your heart go see a gastroenterologist, the gastroenterologist says, oh, this isn't your stomach go see the psychiatrist who says go see the neurologist. I mean, and it just gets cycled. And then they start to think that this is all in their head.

 So once you realise that we don't fully understand what's going on inside women’s bodies yet. and then just advocating for at least some whatever it is that you think you need. You think you need pain relief, you think you need some more testing, have these conversations with these doctors and make sure you have at least one doctor that is, your coach, a doctor that is collecting all of this information for you. So that way you don't get sent to get this test and that test and this test and that test because that's not always good either.

So you need someone that you trust. You need someone that can pull all this information together for you. Involve someone you know, that you're close with that can help advocate for you if needed.

Raquel: Thank you so much for sharing that, that's great advice.

 Just bringing someone who knows what you're like every day and who can say, well, yes, this is not normal for my sister, for my mom's kind of stuff. Like a point of reference.

You're right about the need for a women's health revolution. And you talk about how throughout the 1970s with the advent of reproductive rights and a lot of legal reforms, society began to understand women as different, but not inferior to men.

And now you're saying well, but we need to have a new revolution within society. And in particular, in the medical community to sort of really address that point.

We fought for equality, but we meant equality in job opportunities we didn't mean that we were exactly the same.

Although we women have spent the last several decades fighting for equality, we are also becoming aware sometimes painfully that there are significant differences between men and women. Differences for which our egalitarian vision did not account. These differences are at the heart of this new women's revolution, which is now coming to prominence.

So there's a big push in legislation to promote and even to try to enshrine in legislation, that women and men are exactly the same way. Exactly the same in every way. And that there's no difference between the two. So how do we sort this? So much of the feminist movement has been about arguing that we are just as important as men. That didn't mean that we were exactly the same, but it was about making the point that we deserve the same pay for the same job.

 But now we're at a point in which people are making the assumption that we meant equally in every single way. So how do we deal with that sort of conundrum?

Alyson: It's an interesting question.

I agree that men and women should be considered equal, equal in rights and all of that, that was so necessary to really bring to light before. But we are not scientifically the same. So there's the political piece where we should have access to as much that men have access to.

But when you think about scientifically and biologically, we are not the same. And if you think about it, we haven't been treated equally, when you think about who was enrolled in science, who was able to conduct science.

There's lots of evidence that shows when the researcher is a woman she is more likely to enrol women in the study and to do analysis based on sex and gender. And so that's really important.

It's also been shown that when you have a female physician, that she is more likely to take better care of her female patients than male doctor. And so the more that we align those two, the more that we get more women in leadership positions, more women in STEM and have access to leadership then this will translate to better health in those fields for women.

So I think that that's really, really important to, to make a distinguishment, that there's politics and then there's science. And this is about science. Although we have to make sure that policies are in place that ensure that we are studying women to the same degree that we've studied men.

Raquel: When it comes to the research, do you see opportunities for research that is sex specific or is it like a real battle to get funding into studying these differences?

Alyson: No, I think now we're even sort of evolving past that. In the United States, the NIH is our major funding body and they have requested that if you are applying for a grant to do a study that you include both men and women and that you add the analysis of sex as a biological variable. However, that has not always been followed through.

 I think that anytime you sort of create a new policy, you realize that there has to be the stick, not just the carrot, like here's the money. They've looked at that every time, not every time they've looked at what NIH has funded and someone who said that they were going to look at sex as a biological variable, and then it didn't always translate to what they published.

They're working on processes that make sure that this is followed all the way through, but by no means do you need NIH funding to do research. There's lots of other ways to get funding and those funders don't have these particular protocols or rules for sex and gender right now, so, there's the precedent set by the NIH, um, which needs to get even better.

But it's not a requirement for every other funder out there. So there's definitely some room to improve with this.

But I think where the science is headed in the future is that now when you have a study that shows that - say Ambien, so Ambien was a drug that after being prescribed for over 20 years to women at the dose that it was studied in men, we realised that women were waking up in the morning and were impaired and then they would get into car motor vehicle crashes.

And then we looked at it to say that, oh, if you give the same dose to women that you give to men, it stays in their system. It's two times if you check the serum concentration, it's two times the concentration as it is in men. So by the time we wake up, we still have a half of more of the drug in our system than a man. So that has tremendous consequences.

And so when we look at that now, it's like, okay, well, why is that sex difference there? It's not just that we are realising that women metabolise this drug at a slower rate than men. It's like, why do you want to metabolise this at a slower rate than men?

We're now looking at the enzymes involved, that are in the liver and we're looking at how your body excretes it through the urine and maybe it has to do with body fat differences or, metabolism differences.

So I think it's really opening up our understanding of science to a really interesting degree when now, if we make it a normal rule that we, enrol both men and women, and then we analyse it to see that there are differences. And then we see that those are differences, now the exciting thing is why?

It's been a key to really unlocking maybe some of these conditions that have high public health significance that we can't seem to cure.

Raquel: Yes. And there's a whole thought process going on there that is not sort of automatic.

So it seems like when it comes to the funding from the NIH, is it possible then for people who are doing funding to tick a box and say, yes, we will account for sex differences, but then not have to follow through in their actual studies. Is it like a loophole?

Alyson: There was. There was a government accountability study that actually looked at that.

They realised that even though during the application process and then them being awarded the grant to do the project, that the people who had to follow up with them, you have to sort of give regular updates about your process along the way, that it wasn't part of the checks and balance. Those questions weren't being asked because they just were forgotten about, or it wasn't part of the process of making sure that it was carried through.

And then when you look at publications, one of our biggest challenges is the process of getting your study in the scientific literature, that process is another whole process that that scientists need to go through, they go through peer review and other scientists look at it and the peer reviewers, aren't saying, well, where are the women? The journal editors that actually have the decisions of whether they're going to publish this in their scientific journal aren't thinking or considering this either.

And so there are so many processes along the way even in the research sphere where these types of things could be a chance to be caught or changed or are given the right direction and they're not, so more awareness definitely needs to be had and I think that that process, although complicated needs to be done.

Raquel: Yeah. And then things get a little bit more detailed when it comes to issues of like race and ethnicity. So for example, you talk about, and we've seen a lot of news stories about the way that the medical system treats, for example, black women, and you cite some studies in your book that talk about like black women are three to four times more likely to die in childbirth, 50% more likely to die of breast cancer. 50% less likely to be treated when they arrive at a hospital with symptoms of a heart attack or a coronary disease and 30% more likely to die of heart attacks than white women. And that's just the tip of the iceberg when it comes to these medical issues.

But you're right, that on the whole women of colour are consistently less likely than white women to receive appropriate treatment in all medical settings especially when it comes to pain and non-specific symptoms.

So how is that the knowledge, the dissemination, the research done when it comes to, in particular women of colour, black women, Asian women, Latina women. How is that? We're barely beginning to understand it. It sounds kind of like medieval, but it's like, we're beginning to understand the sex differences between men and women in all of these different medical contexts.

How is that then affecting women of colour when it comes to this same issue?

Alyson: When you look at mortality rates for cardiovascular disease, for instance, and you, and we say that more women, it's the number one killer for both men and women, but more women die from it than men. And then you just look inside the women and you say, well, okay. So among the women, women of colour are more likely to die than women that are white. And so what happens is we have all of these compounding biases that just collect. Sexual orientation is a minority. So if you are gay or lesbian or queer, then you're in the minority. They get less care.

So now, if you're a woman and you are a woman of colour, and then you're also a sexual minority, or you have a disability, all of these things just compile against you. And so I think it's really important that, we're just saying we need to study women, but we need to also look at all these other environmental factors.

If you think about all these environmental issues. So I look at gender as an environmental issue because how you present yourself in society, reflects how your access to care can affect your health.

So if we look at race as an environmental issue, it's visible, lots of genders are visible and people make assumptions. If you have a disability that's visible and then people make assumptions, really looking at all of these aspects when we're considering scientific studies, I think it's really opening up to understanding a lot of the social, environmental consequences of health.

Raquel: I remember when I was a teenager, I don't know, maybe like 12 or 13, I started to have asthma almost every month I had to go to the hospital and they had to- It's the thing that happened before they have to intubate you and stuff. So I would always get very close to that stage. And every time you would talk to the doctors, they would say that I was stressed, they call it a hypochondriac reaction and stuff. And it was only later on that I connected that I was living next to like this factory and this other factory and this other factory, like all of this right in front of like a big highway, there were all of these other factors that could have been affecting my health, but through all this teenage years, the worst thing that you can say to a teenage person, they sort of made it seem that it was all in my head.

And I think that that's the reason why I became so fascinated with this book and this topic in general because I just kept thinking, well, what about all of these people who are still being misdiagnosed, especially women who are being misdiagnosed.

So your work is so important. I just wanted to say, thank you so much for your work.

Alyson: Thank you so much for saying that. And these stories from women are everywhere and being told that it's in your head or being told that you're a hypochondriac, it's infuriating to me.

I think it's really important that we all embrace our sphere of influence in this. So if you are running a book club, there's lots of books out there that a group can discuss this. If you are a CEO of a company, having this be part of your understanding. Wherever your sphere of influence is to really make this a part of it so that way the awareness can expand and hopefully help for a brighter future for women and men.

Raquel: I have one final question.

Why did you decide to name your book Sex Matters? I don't doubt that it does, but I wonder if you could explain to us sort of your thought process in arriving at that title.

Alyson: That's interesting, that title came to me one night while I was sleeping, I like woke up and I thought, oh, I'm going to call it Sex Matters because for me, this is very scientific, each cell has a sex. This is about science. This isn't about politics. This is about health and disease.

And so for me, I really wanted to embrace that particular term because that's what it comes down to for me is really just having the ability to understand our physiology and anatomy even better.

I remember when I first started my division on sex and gender and emergency medicine. It was initially called ‘women's health and emergency care.’ And that was because back then we didn't use the word sex to denote a biological sex. It was considered not okay to use until the NIH used the term sex as a biological variable. And then I thought that's it because whenever I would tell people about ‘women's health and emergency care.’ I would have to explain what I meant. It was always like, well, we don't just do reproductive health. We do that too, that's very important, but it was about the whole body of the women. And so I thought I'm going to stop explaining that. I'd rather explain that what I mean by sex, because it gets right to the heart of the matter, the science.

And so I thought I've embraced that to sort of get away from the term women's health. And I know that now when I refer to women's health in the context, I'll say ‘the health of women’ because women's health has been synonymous with reproductive health. And so now I'll talk about biological sex or social cultural gender and how it impacts, the health of women everywhere.

Raquel: It's an excellent title.

 It just gets straight to the point, just straight to the point, we need to talk about why sex matters because it does.

 Well, thank you so, so much for speaking with our audience here at FiLiA. This has been so instructive. Please buy the book.

It is called Sex Matters: How Male-Centric Medicine Endangers Women's Health and What We Can Do About It.

Alyson, thank you so much.

Alyson: Thank you Raquel for having me. It was lovely.