For centuries, we’ve tended to view specific groups through simplified lenses. We see  children as miniature adults, lacking the complexities and nuances of their elders. On the other hand, women are sometimes defined in relation to men, their experiences and identities framed as the opposite of a masculine norm. However, these reductive perspectives limit our understanding of these groups and can harm health care.

Recognition of pediatrics as a distinct and separate medical field happened gradually, unfolding over centuries with crucial turning points and ongoing progress. The 17th century saw the emergence of figures like Nils Rosén von Rosenstein (1706-1773) in Sweden, who authored The Diseases of Children and their Remedies (1764). Although there were others before this, this was considered the first modern textbook on pediatrics. Its publication marked a shift toward recognizing the distinct features of childhood illnesses.

Only very recently have we seen a similar shift toward sex-based and gender-based medicine. In 2016, the National Institutes of Health (NIH) released a policy stating that research designs and analyses must include “sex as a biological variable.”¹⁴ Even though we are increasingly conscious of specific differences between the male and female bodies when we think of gender, and the spectrum of genders based on social constructs, medicine has lagged in recognizing how biologic and hormonal differences can significantly influence health and disease. For too long in medicine, women’s health has been painted as a mere counterpoint to men’s—a mirror image on the opposite end of the medical spectrum, except with a uterus. But this approach fails to capture the rich tapestry of women’s experiences, leading to misdiagnoses, missed opportunities, and an understanding that doesn’t fit.

Here is where sex and gender medicine enter. Sex-based medicine focuses on biological differences between men and women, typically in anatomy, physiology, and hormones. On the other hand, gender (gender-based) medicine is broader, including social and cultural factors influencing health care outcomes. This field explores how gender roles, power dynamics, and societal expectations impact health outcomes for different groups. Considering these differences, gender medicine can improve health care for all people, regardless of gender identity. Sex and gender medicine focuses on personalized health care that recognizes individual differences in biology and social experiences, offering tailored treatments and interventions. By promoting an inclusive and equitable approach to health care, sex and gender medicine can potentially improve health outcomes for everyone.

So why should we care about this in emergency medicine?

Several compelling reasons demonstrate why focusing on sex and gender medicine within the emergency department holds significant value. I recently interviewed Alyson McGregor, MD, an emergency physician, a sex and gender medicine expert, and author of the book, Sex Matters: How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It, who provided additional insight.

First, Dr. McGregor emphasized that we can improve our clinical accuracy. Men and women often present with different symptoms and respond differently to treatments for the same condition. Understanding these sex-based differences can help emergency clinicians arrive at a faster and more accurate diagnosis, leading to quicker and more effective interventions.

Second, we may be able to avoid some adverse drug reactions. Studies have shown that women experience adverse drug reactions, including nausea and seizures, at nearly twice the rate of men.² These reactions are significantly more likely to lead to hospitalization in women as well.⁹ The practice of prescribing equal drug doses to women and men fails to account for sex differences in pharmacokinetics, body fat percentages, and weight, ultimately leading to overmedication of women.¹²

Third, we can create a more equitable and effective health care system. Historically, medical research and practice have often overlooked or minimized the unique health needs of women and people of diverse genders. Gender medicine helps close this gap by providing a more comprehensive understanding of health and disease across the gender spectrum.

For what kinds of diagnoses should we consider gender differences when seeing patients on shift?

1. Cardiac disease—Although females are affected by the traditional risk factors for ischemic heart disease, such as hypertension and smoking, there are sex-specific non-Framingham risk factors that put certain females at higher risk. For example, if a female had pre-eclampsia in her pregnancy, this doubles the risk of future strokes and quadruples the risk of hypertension later in life. Thus, when considering a females cardiac risk, it is important to obtain a pregnancy history.^8,11
2. Atrial fibrillation and stroke—Several studies have shown a higher risk of stroke in females than in males who have atrial fibrillation. American atrial fibrillation guidelines have included female sex as part of risk stratification models, including the CHA2DS2-VASc score.^4,10
3. Seizures—Catamenial epilepsy, which is characterized by seizures that worsen during certain phases of the menstrual cycle, affects around 40 percent of females with epilepsy.^6,7 Circulating levels of estrogen and progesterone play a role in seizure susceptibility. Females with these types of seizures may require hormonal adjuncts or a temporary increase in their anti-epileptic drug during a specific part of the menstrual cycle to control their seizures. Furthermore, as Dr. McGregor noted, the pharmacokinetics of some anti-epileptic medications such as lamotrigine may play a role in seizure activity around the time of menstruation in epileptic females.³
4. Pain management—Studies have shown sex differences in nociception across multiple stimulus modalities. Women tend to have higher pain sensitivity compared with males and perceive more pain than men. Estrogen and progesterone’s roles in this finding are multifactorial, but studies have also shown that testosterone may have an anti-nociceptive effect.¹

We now understand that gender medicine is essential in our practice. What can we do about it? Dr. McGregor provided a few resources:

• Dr. McGregor keeps a PubMed search tool on sexandgenderhealth.org up during her shift. Here, you can see updated evidence on multiple disease processes that will help you care for your patients at the bedside.
• A new textbook, How Sex and Gender Impact Clinical Practice, provides tables, charts, and evidenced-based information about gender differences.
• Dr. McGregor also wrote a book, Sex and Gender in Acute Care Medicine, which is a reference for sex and gender differences in patients presenting to the emergency department.

Sex and gender medicine is not about treating men and women differently for everything. It’s about recognizing that biological and social factors influence health differently in each sex and gender identity. By embracing this knowledge, we, as emergency physicians, can provide better care for all our patients, regardless of their biology and background.

Dr. Kendall is the chief of clinician engagement at US Acute Care Solutions and has 15 years of emergency department leadership experience. She is the chair of the USACS diversity, equity, and inclusion committee, the social issues and equity in medicine committee co-chair, and leads physician leadership development for USACS.

References

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3. Herzog AG, Klein P, Rand BJ. Three patterns of catamenial epilepsy. Epilepsia. 1997;38(10):1082-1088.
4. Lip GYH, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137(2):263-272.
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11. Ospel JM, Schaafsma JD, Leslie-Mazwi TM, et al. Toward a better understanding of sex- and gender-related differences in endovascular stroke treatment: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2022;53(8):e396-e406.
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14. U.S. Department of Health and Human Services (n.d.). NIH policy on sex as a biological variable. National Institutes of Health. https://orwh.od.nih.gov/sex-gender/orwh-mission-area-sex-gender-in-research/nih-policy-on-sex-as-biological-variable.