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Abstract
Sex and gender are both critical variables that affect health and illness. Gender is a social science descriptor and sex is a biological one. Gender and possibly sex are not binary variables.That we think of them as such is a political decision rather than a description of the natural world. It may be scientifically more accurate to treat them as continuous variables for the purposes of research. Wherever possible, scientific research will benefit from treating men and women as separate populations, or modeling sex and gender as continuous variables. It is time to move on from the foundation built on the European male as the model human. The dominance of this model is a result of a fierce battle between competing world views over thousands of years. The masculine perspective won that battle, as recorded in the myths and legends of Europe and other cultures. In the process, the feminine was suppressed, women became invisible, and their contributions to the creation of knowledge disappeared. The rule of the fathers brought with it a binary foundation to thinking and the preeminence of rational thought. Feelings, intuition, and nature were abhorred. Nature was a force to be conquered. Distrust of the feminine has been deeply embedded in the development of the science on which medicine is based, with important consequences that are considered by the authors of this textbook. No problem can be solved from the consciousness that created it. It is time to combine the biological and social sciences to unleash a revolution in scientific thought appropriate for the 21st century.
Copyright © 2012 S. Karger AG, Basel
In the age of personalized medicine that seeks to apply targeted individualized therapy, we seem to have missed two of the most overt genotypes and phenotypes that patients present with: those of sex and gender. Personalized medicine requires understanding the impact of the X and Y chromosomes on the molecular profile of women and men, and the health effects of gender roles ascribed to men and women and those with other gender identities.
Western science is now ready to move through the gateway from medical science built on the foundations of reductionist linear thinking that defined all patients in relation to the 70-kg European male, to an expansive capability that includes in scientific understanding of disease and medical care the complexity of the whole person that is the patient.
An example of the importance of identifying the impact of gender and sex can be seen in prostate cancer and lung disease. When masculinity is defined through the qualities of a warrior it is difficult to admit to weakness or to seek care. The resulting delay in responding to symptoms leads to worse outcomes in prostate disease that are a result of gender, not changes in testosterone. In women, the increasing incidence of lung cancer began when it became acceptable for women to smoke, a change in gender rules, not estrogen. It has become apparent that women with lung cancer live longer than men, even when known prognostic factors are controlled for. This is a survival outcome determined by sex, and the research design required to explore this must test the data on women and men separately.
To understand the importance of this textbook in the development of biomedical thought, it is necessary to grasp the essential elements of how things got to be the way they are. We are at a point of transition in the history of thought in the Western tradition. The transition is from 3,000 years in which humans have refined intellectual thought through the use of reason and the order of the father right, to a new point in which the feminine is re-emerging and with it expanded ways of knowing. The consequences are being felt in all spheres of human activity, including in the construction of scientific thought and medicine.
The stories about how things came to be the way they are are told in myths and legends, and we would do well to know what they are, for myths set the tone for a whole society. European myths tell how the feminine was defeated in epic battles between the goddesses and the gods. The gods won, and from that time on men as their representatives on earth took on the roles of leadership, politics, war, and knowledge making. In the process, the feminine was ruthlessly suppressed and women became invisible, their contributions to the creation of knowledge erased from public consciousness.
The mythical defeat of the feminine has its parallel in the real world. One of the most savage ways it manifested in Europe was through the Inquisition, a systematic attack on women and the feminine that at some points particularly targeted women who were healers and named them as witches.
Witches lost their central place in theorizing during the 18th century, when natural philosophy was radically reconstituted. Natural theology (which required divine intervention in the order of things) was replaced by rational theology in which God was held to be omniscient and prescient rather than interventionist in a daily sense. With rational theology came rational science, a science based on observation and an understanding of the ordered nature of nature, a ‘mechanical’ view of nature that has prevailed since. The witch burnings, then, could be considered part of the process of science cleansing itself of magic, part of the triumph of mechanistic thinking ushered in by Descartes. The witch burnings were the backdrop to the fierce competition among medical paradigms - Galenist, Paracelsian, iatrochemical, mechanistic - that was part of the scientific revolution of the early modern age.
Rational thought became the science on which modern medicine is based, and it contains within it a horror of magic, nature, chaos, intuition, and the feminine. The medical profession was developed in part to distinguish itself from the activities of others who claimed to heal, at a time when women and the feminine had been tortured into silence. That modern science, and with it modern medicine, were deeply implicated in the reification of the masculine, and rose from the ashes of the witches’ pyre, makes the relationship between the feminine and medicine highly problematic. Distrust and fear of the feminine remains deeply embedded in medicine as an inadequately identified legacy with hidden consequences that this book’s authors are opening to scrutiny. It is essential to come to grips with this engendering of medical knowledge if we are to understand how gender and medicine interact.
Gender, of course, includes all sexes and sexual identities and is not code for women; however women are the missing majority. This is the right time to grapple with the idea that gender, and possibly sex, are not binary phenomena and that they are described as such in scientific literature as the result of acts of power that have made sexual and gender variability sources of hostility and invisibility. The need to ensure that sex is dichotomous is not universal, and many Asian and traditional cultures have spaces for people who identify as neither exclusively female nor male. Sex and gender may be better considered as a fluid continuum along which people can position themselves variously during their lives.
In one Australian Indigenous culture, boys and girls can choose their gender roles and change them during their lifetime, and there is no such thing as sexual ambiguity because you are who you are. This is a radically transformative thought. It has the power to break apart the dichotomous thinking that underpins the power systems that are in place now. The work of gender and medicine has this power to transform science and clinical care.
The philosophy of Plato that created dichotomous thought was the means by which Western systems created binary categories to help order a disordered universe, including male and female. These categories extended beyond the sexual divide to include foundational concepts such as good and bad, mind and emotion, science and nature, knowledge and opinion, and soul and body. The technical consequences of dualism are the science and digital revolution we are living through today. The political consequences were that all of the good, mind, science, knowledge, and soul categories were joined together in a slippery move that aligned them with male and left female embedded within all that was unknowable and mysterious.
The Christian Bible then compounded the divide by commanding man to have dominion over