The History of Women's Health

In this episode, we dive into the history of women’s health, from ancient myths to modern research gaps. We are joined by Dr. Tamil Kendall, Director of the Partnership for Women’s Health Research Canada, who walks us through how women, trans, and non-binary people have been excluded from clinical research, the evolution of contraception, the impact of abortion legalization, and why understanding this history is essential for shaping a healthier, more equitable future.

Join us for an eye-opening conversation that connects the past to the urgent issues in women’s health today.

Transcript

Tamil: 0:00

There's a long thread in our Western medical history that really does, stigmatize women's sexuality, and blame women's sexuality for their behavior that might be non-conforming with the way that they're supposed to act in society. Today, probably our biggest misconception around women or females is that they are little men and therefore can be treated as little men. Over a four year period in the United States, eight of the 10 drugs that were withdrawn from market were withdrawn primarily because they have more adverse effects in women. The Canadian Institutes of Health Research in 2023 only spent 7% of their budget on female specific and women's health research. So we need to change that

Sabrina/Mathilde: 1:23

Hello everyone. Welcome to the Volvo Evolution Podcast. So today we're really excited to have with us Dr. Tamil Kendall. She is the director of the Partnership of Women's Health Research Canada, where she works to advance women's trends and non-binary people's health through research, policy and practice. We are so lucky to have Tamil here today. She has over 20 years of experience at the intersection of women's health and rights, collaborating with community-based organization, governments, universities, and the United Nations. She's also an adjunct professor at the University of British Columbia. Her academic journey has taken her from a Bachelor's in History and Women's Studies at the University of Ottawa to a Master's in Communication Studies at Simon Fraser, a PhD in Anthropology and Health Sciences at UBC. And finally, a post doctoral fellowship with the Women's in Health Initiative at the Harvard School of Public Health. So we are so excited to dive into the history of women's health today. So welcome to the volution, Dr. Tamil Kendall.

Tamil: 2:34

Thank you so much for the invitation. It's fun to be here with you.

Sabrina/Mathilde: 2:39

Yeah, thank you so much for joining us. Probably taking time out of your very, very busy day doing very, very important things. So we're so glad you are here with us. We were thinking we could start, with you just sharing with our audience a bit about what you do, and what brought you into the women's health field.

Tamil: 2:56

So I was raised by, a second wave feminist, my mom. And so I was very interested in women's health and rights and identified, as a feminist from a very young age. So when I was doing my undergraduate degree, for example, I was part of a feminist collective that did a newsletter that we distributed at the University of Ottawa. And in my professional career. I was always working on, women's health in rights issues, especially in the area of sexual and reproductive health. And especially working with women living with HIV, who historically have faced a lot of stigma and discrimination around their sexuality and reproduction. So that was some of the evidence-based advocacy and community-based research work that I did in the past. And today, I lead the partnership for Women's Health Research Canada, which is a collaboration between the Women's Health Research Institute in bc. The Women and Children's Health Research Institute in Alberta Women's College Hospital in Ontario and IWK Health, and we are committed to the idea that better research, makes better health and that equitable, diverse, inclusive health research is needed and that this is really an unfinished agenda in Canada. So, just as an example of that, the Canadian Institutes of Health Research in 2023 only spent 7% of their budget on female specific and women's health research. So we need to change that so that all women, trans and non-binary people can enjoy the benefits of science. So in my day job, I work on advocacy issues like that, but also, provide a platform for the fantastic women's health researchers, including trainees that we have across Canada to share the work that they're doing in the women's health research space.

Sabrina/Mathilde: 5:07

So if I understand correctly, you're bringing together people that are studying women, trans and non-binary people to talk about their research

Tamil: 5:17

That's one of the things that we do. So since 2022, power has run a quarterly seminar series. And so we brought researchers, our community members, together to talk about the research that they're doing, to advance women's, trans and non-binary health.

Sabrina/Mathilde: 5:37

why do you think it's so important to bring researchers, that are studying, this specific population of women, trans and non-binary people? Why is it so important that we talk about it and we bring them together?

Tamil: 5:49

Well, one reason why is to share our lessons learned. So at Power we focused a lot on how to do engaged research and how research is actually being translated into action to improve the standard of care for people. And I would say in BC we're very lucky, across the country we're very lucky. But NBC, there are two examples of researchers who had. Done this incredibly well, who immediately come to mind. And that's Dr. Gina Ogilvy, who has been a leader in the space of bringing HPV self-testing to British Columbia. Um, and Dr. Wendy Norman, who first made the case for why universal contraception was so important and cost saving over time for the provincial government, and worked very closely with policymakers in order to bring that into being in bc. And I think that that then had a role in setting that as part of PharmaCare, on the national agenda. So I think that all of us can learn from these kinds of examples, and one of our goals at Power is to list those up and make them more known and inspire researchers. But I think, the other reason is that we want to a network across the country of researchers, including trainees who know each other, know about work that is happening across the country because that creates more opportunities.

Sabrina/Mathilde: 7:28

Yeah and it's really great to be in BC right now, I know there's other provinces in Canada that maybe are still struggling with some of the things like that, so it's great that we have researchers like that pushing it and it's great that we have power and mm-hmm. Organizations like this to connect them all and yes, bring forward that research

Tamil: 7:46

Well, and let me give another example because of course. We lead from everywhere. So very exciting, for example, at the University of Alberta to see the kind of ongoing partnership that they have with indigenous communities to do research and how that has evolved over time. So that's incredibly impressive. Or, in the Maritimes seeing fantastic work happening around management of pain in hospital settings and really putting patients at the center of that, pain management and really taking, women and their paying seriously. Or, in Ontario, groundbreaking work around, serving, survivors, trans survivors of sexual assault. So wherever we look in the country there is just fantastic. Research that is changing with standard of care.

Sabrina/Mathilde: 8:44

Yeah. That's so great to know. So great to hear. I think all of our listeners will be thrilled to hear that. Yeah. Everywhere is doing really important research all across Canada. Yeah, because it, it wasn't like that before, which is what we're gonna talk today. Yeah. So let's get into the history. We're so glad to have you here with an anthropology background as well as the research experience. We think you're gonna bring such an interesting lens to this conversation. So let's start way back at the beginning. So way back in Greek and Egyptian times, there were some pretty. Interesting interpretations of women's health issues, and they even had this idea of a wandering womb where the uterus could move around the body and cause issues, and that was sort of to blame for a lot of women's health issues that we now think are, you know, have real diagnosis and have real symptoms that you can test for. What do you think was the motivation behind this idea of a wandering womb? Do you think that that was reflected of the understandings at the time? Do you think it had anything to do with perspectives around women being maybe lesser than? What's your take on all of that?

Tamil: 9:55

Well, medicine was very different at that time, than it is today. But what I would say is common, is this idea of the female as a deficient male in some way, and also the idea that women's sexuality causes them to be ill. So if we look at hysteria, so hysteria comes from the word in Greek hyster or uterus, right? And we, and we look later in time in the 19th century when medicine looks a bit more like it does now there was the practice of hysterectomies in order to address women's mental health issues, for example, or very, gender divergent treatments for hysteria where they would give women a rest cure. So not let them read, not let them do any work. Whereas for men, they would recommend for the same symptoms, vigorous exercise. So today we know that in fact for mild or moderate depression or anxiety, exercise is one of the best things that you can do. Whereas being constrained and not having any intellectual or physical stimulation whatsoever probably wasn't, the best outcome for women. But I think that there's a long thread in our Western medical tradition and its history that really does, stigmatize women's sexuality, and blame women's sexuality for their behavior that might be non-conforming with the way that they're supposed to act in society. So that's an ongoing thread. Today, probably our biggest misconception around women or females is that they are little men and therefore can be treated as little men. And that's where the huge knowledge gap that we have, in health research, in medical research, it causes problems. So most of what we know about how to diagnose and how to treat has come from studies in males. And now we know that every cell is sexed and that actually, male and female bodies achieve potentially the same functions, but through very different pathways. And that has a huge impact on how we can prevent and treat different medical conditions. So we certainly need more research in order to be able to do better.

Sabrina/Mathilde: 12:47

Yeah. Oh wow. It's so interesting to know. Like we just said that it was Greek or very a while ago, like it's a hundred hundreds and years ago, and there's still echoes of this to this day. Can we move on to one very important wave of feminism that happened in the 1960 that was marked with a big women's health movement, an activist that began to challenge the male dominated medical system and fought for healthcare, that was clear, accessible and centered on women. So why do you think women in the 1960s started pushing so hard for access to health information, especially about their reproductive health? Like, why did they feel like they really needed to, make a change and why? What did it happen in the 1960s? Specifically?

Tamil: 13:52

Well that was a time of great social change, I think in North America and in Europe and elsewhere. And some people would say upheaval. So there was development of the counterculture. There was huge opposition in the United States to the Vietnam War that in some senses was an intergenerational confrontation between the young people and their parents. And there were changing norms, in society, including because of the feminist movement that at that time was demanding equal rights and opportunities for women. And there were more women, than ever accessing post-secondary education at this time. And then also. Um, you know, most women have always been in the workforce, but you also saw middle class and upper middle class and rich women working outside of the home, very, very actively in this period. And so, that was, that was part of the change. And, this demand around reproductive rights, was a, a clearly articulated demand at that time, both for contraception, and abortion. And there were also some changes around, sexual norms at that time, to some extent around premarital sex. So there was, you know, there's changing social norms at that time and I think that that really put reproductive rights and health at the center of part of those. Demands.

Sabrina/Mathilde: 15:33

I think that you mentioned there, and we wanna get a bit more into a big part of that movement, was the introduction of the pill or contraceptives in general. I think that nowadays we've come to be kind of used to having access to contraceptives and nowadays we have many different ones, especially. In bc it's now free to have contraceptives if you are a BC resident. But I think at the time these women had no other forms of contraceptives. So what can you tell us about what this really would've meant for these women to have control over their reproductive freedom?

Tamil: 16:08

well, I have to say, I mean, humans have been contracepting for a very, very long time, so. They have been paying attention to their menstrual cycle. They've been practicing extended periods of breastfeeding, which can prevent for the first six months, and then reduce the possibility of pregnancy. Um, and they've been using various forms of condoms or different barrier methods for a very long time as well. So the pill wasn't, totally new, but it certainly was one not so user dependent, which is very important for contraceptive effectiveness. And it was, more reliable, more effective in normal use than these other methods that preceded it. But back to why it changes things is that that ability to exercise your reproductive rights, so the right to choose the number and spacing of your children really opens up other opportunities. So participation in education or higher education, participation in the workforce. So it transforms, women and other birthing people's lives by allowing them to make choices about when they have children. And this may be an important riff on the discussion of second wave feminism and, the big focus there on contraception and abortion. This was mostly from a white, middle class woman's perspective, and what we see coming alongside it, and a little later, is this concept of reproductive justice that actually comes from women of color in the United States as they get ready to go to the International Conference on population and development, which is where those reproductive rights are articulated and enshrined for the first time in a UN convention, they say, you know, for us it's not only about access to the pill or access to abortion, it's a broader right. About being able to choose when we have children. And so they, said this beautiful phrase, and this was sister song. It says, the human right to maintain personal bodily autonomy, have children not have children, and parent the children we have in safe and sustainable communities. And so here you start to see a much broader kind of conceptualization of what reproductive rights are, and starting to bring in these environmental threads and, the cultural self-determination threads into that conversation. So I think that, it's really interesting to think about those technologies, but also to understand the social settings that they, that they go into and how those vary.

Sabrina/Mathilde: 19:28

True. Wow. Yeah. No, it's, it's so interesting, and I think you really alluded to this, but it really would've, opened up so many more opportunities when you have control over when you're having kids and if you're going to have them. 'cause then you can get education and that opens up so many more doors. So I think that it's kind of like, seems almost like a little stepping stone to have access to reliable contraception, but the follow up to that is so huge for women's rights in general. Mm-hmm. By giving them more control over their body and Absolutely. Yeah. Yeah. Which should be like bare minimum. Yeah. What can you tell us about the development of contraceptives?

Tamil: 20:08

Well, unfortunately, this is a very, sad story so in the, in the development of the pill, for example, a lot of the medical testing was actually done in Puerto Rico. Um, in the development of the implant, a lot of that medical testing was done in Indonesia and not necessarily with what we would consider appropriate, dosing in the case of Puerto Rico, but also, uh, in informed consent, for the use of those methods. And that has created a very unfortunate side effect where for good reasons, many of these communities of color, because of these historical experiences, can have a lot of distrust of the medical system and of the information that's provided in the medical system. And so we need to decolonize and work towards being anti-racist health systems that really treat people with respect and take informed consent and excellent counseling for contraceptive methods as the bare minimum so that people are really able to make those choices for themselves. So that is part of the, the sad history of how classism and racism have functioned in many forms of medical research in the past, including in contraceptive development. But something, important happened there in the eighties and nineties, which was about feminists of color or people interested in women's rights. Started to engage a lot more and to articulate their interests and their demands. And is what created the movement that we call third wave feminism, which is a much more inclusive feminist movement that looks at the issue of intersectionality. So how do different identities combine and reinforce each other to create social experience? And I would say today there is much more attention to, to intersectionality in women's health, in feminism and in women's health research. So that brought about a very positive, positive change in that way, to say, no, it's not just, about having access to contraception or abortion. It's also about my ability to have access to a safe apartment and enough food and appropriate food so that I can take care of and raise this child's in a good way. And that that's also part of reproductive rights. So I have a lot of respect and appreciation for the feminists of color that led that charge and to the white women feminists that were willing to engage in that dialogue and create more of a collective lifting up.

Sabrina/Mathilde: 23:34

Wow. Yeah. Yeah. A sad history that evolved into something much bigger and much, much better. Mm-hmm. When it's more inclusive. Absolutely. Yeah. Thanks to all of these women, we wouldn't be here today without you. Okay, so moving on. In 1973, there was the release of a very important book called Our Bodies Ourselves. And it included a lot of different chapters about a lot of different groundbreaking things about women's health that at the time people didn't have access to. Some people were aware of these things, but general population did not have access in a format such as a book, which is really accessible to the general population to understand their bodies or understand their sexuality or anything like that. And this book was huge at the time. Revolutionary, I'd say maybe even revolutionary. What can you tell us about this book and what it did for women at the time for, you know, learning about themselves and learning about their sexuality and health?

Tamil: 24:40

I wasn't there. But my understanding, you know, this was very much part of the counterculture ethos and of the feminist movement at that time. Right. What was happening people who identified as women were getting together in small groups, and they were talking about their experiences. So they were called consciousness raising groups. Right. They were sharing how they have lived their lives and what they dreamed of. And part of that was this focus also on bodily autonomy and female sexual pleasure, which was really new and I would say is something that we still, don't pay enough attention to. There's still not enough knowledge really about. Female anatomy and sexual pleasure. And so we're still on the journey, but it was quite revolutionary at that time to have this book being passed around before it was published as a book. And photocopies in different groups of women across the country in the United States and beyond, looking at these and, you know, getting out the mirrors and looking at their own genitals for the first time. And people encouraging other people to, you know, try masturbation, see what it feels like, touch your own genitals. And the, this was a really important part of empowerment. I would say women's sexual empowerment this particular road, as well as providing kind of laid person's information about different contraceptive methods, sexually transmitted infections, and those kinds of issues, but it was very grassroots and that was, kind of typical of this, this counterculture movement.

Sabrina/Mathilde: 26:35

Hmm. I think it sounds like a really great book. We still have to read it. I think it's on our bucket list to read this book. Yeah. Um, but it wasn't liked by everyone. It was even banned in some high school. Why do you think giving women access to these unfiltered knowledge about their bodies and how to give themselves more pleasure? Why was it threatening to some people?

Tamil: 27:01

Well, this was a very revolutionary thing to do. We were still in an era when the broad social norms were that women. Didn't have or shouldn't be interested in sexual pleasure. I think it's quite similar to the kind of discussions that we're having about banning books in schools today when those books talk about, gender identity, right? We know that gendered identity is a spectrum, and that people can express their gender identity in ways that, is different from their sex assigned at birth. And yet we're having this kind of moral panic moment, which is politically motivated to say, we don't want children to be able to access information about gender identity. Well, removing information doesn't make an issue go away. It just limits the ability to exercise informed choice around these issues. So I think that it was seen as quite revolutionary to talk about female sexuality and contraception just at that time. And indeed, I have to say, in 1973, our bodies ourselves was published, and that's the year that Roe versus Wade the decision was made by the Supreme Court to legalize abortion in the United States. So we see this kind of cultural norm and McCourt, uh, expressing that support for the right to choose for a reproductive right. Now we're in a different historical moment, right? So the Supreme Court in the United States struck down Roe versus Wade in 2022, and now we're having a real backlash moment against against gender identity and diversity as well as against women's reproductive rights, abortion, but also a moment that is in some ways very prenatal list, and pushing for aversion of femininity that is a bit traditional in some of its expressions, right? And so it's important in this moment to be guided by the science. And to be vigilant about human rights, including women's rights, trans rights, and reproductive rights.

Sabrina/Mathilde: 29:45

Yeah. Yeah, I think there's a lot of misinformation and like pushing of potentially part of these movements through social media. It's a bit of a scary time to be on social media, seeing all of those. Movements being pushed and anti-woman, anti trans, non-binary. Yeah. Yeah. So it's a, I really liked your reflection on that. Mm-hmm. And how historically, you know, we maybe were in that phase before And you touch on a little bit about abortion and people were getting abortion even before it got legalized. Do you wanna maybe touch on, explain a little bit what type of service looked like, and were there mostly midwives that were offering the service, or was it doctors or how did it look before?

Tamil: 30:30

Well, this as always is a discussion about privilege when abortion is illegal, it's about the quality of abortion that you can pay for and the quality of abortion provider that you can pay for. And so if you are a very wealthy woman or your family has money. It doesn't really matter usually about the legality of abortion. You're able to either travel to a place where you can have an abortion legally, or in the place where an abortion is illegal, you're able to access a high quality abortion from a medical provider. For those that are not so fortunate, abortion can become and is very dangerous, because they are using methods that are being provided either by lay people or by not very highly skilled providers, and those have complications. So really what we know about the legality of abortion is that abortion being illegal doesn't stop abortion. As Steve said, abortion being illegal increases maternal mortality. So deaths either after an abortion, or around the time of an abortion. So probably the clearest example of that, the historical example that we have is from Romania in mid 1980s, which there was a dictatorship and all forms of contraception were restricted and abortion was illegal. And at that time Romania had the highest maternal mortality rate of any country in Europe. The dictator was overthrown in 1989, and the next year you saw the maternal mortality rate cut in half because abortion was legalized and there was access to contraception. And we are seeing the same thing now in the United States. So in those states that have banned abortion, the maternal mortality rate is twice that of the states where abortion is legal. And partially that is not only about abortion, but the chilling kind of effect that it creates for women's health and obstetric and gynecological services in those places. First providers, obstetricians and gynecologists are leaving those states and going to other states. Medical residents are choosing not to train in those states that have the abortion bans and then the type of healthcare that's provided. So for example, A DNC, an abortion for an ectopic pregnancy to save the woman's life, which should always happen. Either providers are not providing it because they're afraid that they will be charged. Or because they actually are not allowed to provide it in some states because there's a complete ban. And then we also see, and this is more from what I know, working in international context where the practice of abortion is criminalized. It also creates a situation where women can be seeking medical care for a spontaneous, not an induced abortion. A spontaneous abortion would be a miscarriage. So that is, you didn't provoke the abortion. And they can also be criminalized in that situation, right? Women should never be criminalized, whether it's an induced or a spontaneous abortion, but it creates a climate of fear between healthcare providers and those that are seeking services. So, abortion saves women's lives

Sabrina/Mathilde: 34:32

Yeah. Period. Period. On the topic of abortion. Nowadays we have access to what some people might call like a medical abortion or using a pill for an abortion. The scientific term is Myth Opry Stone. Hopefully I'm saying that right. But it didn't become available in Canada until around the like 2015 to 2019, but it had been around for a longer period than that. Can you tell us anything about why it took so long to become fully available in Canada?

Tamil: 35:03

Well, the short version is that the manufacturer didn't apply for a license in Canada, I believe, until 2012 even though it had been available, in France since I believe 1984 and had been widely used. In very many countries for a long time. So Canada was very late to having an application to provide, miry stone. But the good news here is that because of the strength of our women's health research, healthcare provider community, our research community, and the willingness of our policymakers in Canada to engage in an evidence-based, a science-based discussion around the appropriate regulations to make sure that Opry stone abortion medication abortion was safe, but also accessible. We in Canada have, one of the best regulatory regimens, a unique regulatory regimen where medication abortion. Is prescribed as other prescriptions are prescribed. And so we actually have one of the best, the most accessible, regulatory frameworks for medication abortion in the world. And our researchers have proven that it's completely safe.

Sabrina/Mathilde: 36:33

Nice. Love to hear that. Great comeback from Canada.

Tamil: 36:36

expect the great comeback, Hannah, we were very slow to get there, but now it's, it's being introduced in a very good way.

Sabrina/Mathilde: 36:46

Yeah. And I just have a follow up question. I guess just for our audience, can you just briefly explain the difference between the Plan B pill and the abortion pill so that people don't get confused with the two of them? 'cause they're not the same.

Tamil: 37:00

So Plan B is emergency contraception, so it is to stop pregnancy from occurring. If you're taking a medication, abortion pregnancy has already occurred, you're pregnant, and then you would take these medications in order to provoke, a miscarriage, essentially to provoke an abortion. I will say that, there is another option for emergency contraception, and that is the insertion of an IUD because if you have ovulated already emergency contraception plan B will not prevent you from getting pregnant. So there is another option, which is insertion of an IUD for emergency contraceptive purposes, but yes, very different.

Sabrina/Mathilde: 38:02

wait, that's super interesting. I've never, I've never heard of that, but this is why we have these conversations. Yeah. Learn more about our options. Wow. Yeah. Okay. Let's move on to more of the history of women's health research. So we've alluded to this, I think, and a, a lot of people are familiar with this idea, but for a long time, women weren't included in clinical trials at all, and that started in 1977, officially when the FDA. Kind of tried to eliminate anyone of childbearing potential from clinical research studies. Can you tell us a bit about what motivated that decision or like It's pretty drastic, so what was happening in order for people to think that that was the best option at the time?

Tamil: 38:49

So this has to do with the thalidomide tragedy, which was a drug that was, prescribed during pregnancy. And caused severe deformities, among the offspring of women who took it. And this drug thalidomide was sold in Canada, from around 1953 until 1962. So there was an increased awareness of what they call teratogenic. So that means the ability to harm the fetus in utero, of medications. So that was a motivating factor in excluding any one of childbearing potential from clinical trials. And to this day, pregnant, women and people and lactating, people are not included in many clinical trials. And this can be problematic. There, there is a need to include pregnant people in clinical trials because, you know, 80% of pregnant people take medications while they're pregnant. And so there are ways that we can learn more through what they call pharmaco epidemiology. So by studying, aftermarket. So the drug is already available and you're studying what happens in real life in the population. So that's one way to approach it. But there's also a need to, when the safety profile of the drug, seems appropriate to include pregnant people in clinical trials. And then there's the people that are not pregnant and are using effective contraception that were banned from participating in the past and really should be able to participate fully in clinical trials. So if we think about, the physician studies, so this was 1982 to 1995, and it asked the question, can taking daily aspirin reduce the risk of heart disease? It had more than 22,000 men in it and zero women.

Sabrina/Mathilde: 41:17

Whoa. 23,000 men, zero women. That's like.

Tamil: 41:24

a multiple risk factor intervention, trial for dietary changes and exercise to prevent heart disease. 13,000 men, zero women.

Sabrina/Mathilde: 41:36

Oh my

Tamil: 41:36

So. So as you said, I believe the policy work has been done now, and that changed, in the United States back in 1993. And then in 1997, health Canada actually recommended the inclusion of women in clinical research in Canada. But there's been really slow progress towards actually including females in clinical research. So if we look at between 2016 and 2019 in clinical trials for types of cancers, psychiatric disorders, and cardiovascular disease that don't predominantly affect either women or men, so either females or male, one sex or another, the proportion of females included in all of those clinical trials was less than the disease burden. So we still have work to do to get, more women and trans and non-binary people into clinical trials.

Sabrina/Mathilde: 42:39

Yeah. I feel like it's pretty obvious if we've, we've been excluded from clinical trials for so many years. What can you tell us about the effects of that on the medications we're using and these things that we're all tested on males? What's the effect of that for women and females taking those today?

Tamil: 42:58

One of the examples that is frequently cited is that over a four year period in the United States, eight of the 10 drugs that were withdrawn from market were withdrawn primarily because they have more adverse effects in women. And so this is just about doing rigorous science. Bodies are sexed, cells are sexed. They function in different ways. And so we need to understand how they actually function, and they need to be tested on both males and females to know that they're safe for both males and females in the population. Also, diseases can manifest themselves in different ways. So that has been very important in heart disease and we're making progress, but there's still a long way to go. So, women, they're less likely to have the kind of dramatic heart attacks with with blocked arteries. So Macrovascular disease. In cardiovascular disease, then microvascular disease, which is like the little tiny capillaries. And so women's heart attacks, a proportion of them present very differently. And all our tools for how are we going to diagnose how severe this heart attack is, and then how are we going to triage this person and decide what kind of treatment they get. These have all been tested on predominantly male samples. And so not taking sex and gender into account, means that women are less likely to be treated appropriately for what's actually happening to them. And we know, and this is research from BC when you provide. Appropriate care, specialized women's heart healthcare to those women with microvascular disease, they do much better. So we need to do more research so that we actually know how to prevent and how to treat.

Sabrina/Mathilde: 45:03

More awareness just about, you know, if you are having heart attack symptoms as a woman, it might look very different than as a male. So just that awareness is really important. Grey's Anatomy actually brought some awareness to that. Anyone who's a Grey's Anatomy fan, not good science and medicine evidence all around, but they did talk about heart attacks and how they're different. So maybe some people are aware of that, but I think that we definitely need to start having more conversations of how symptoms and side effects manifest differently in females than in males. Yeah. It almost sounds like for some disease there might be a need for different screening methods, totally depending on sex.

Tamil: 45:41

Such a great point. And actually someone did that with the algorithm that's used for triage of heart attacks. They included sex and gender. This was a big multinational study. And updating the tool to take sex into account resulted in about six, five to 6% of women being reclassified from low or intermediate risk to high risk. So they would get more aggressive treatment earlier and that might be lifesaving, right? So that's a great example of how we do need to update, the information so that we can update our tools, so that we can provide better clinical care.

Sabrina/Mathilde: 46:25

Yeah, because as a side note, I studied nutrition in my undergrad, and in nutrition you have different guidelines for different sex. So for females you have more needs of some types of vitamins or less needs of certain types of vitamins, different between ages and sex. And so in medicine it could also look a little bit like that 'cause we're so different. Yeah. I think it comes back to that idea that we're just small males. Yeah. And we're not, we're not surprised. So I think that's a great point. Yeah. Okay. Wow. Very interesting. Super interesting conversation. Conversation and great examples to show how impactful, just changing things like mm-hmm. Being more aware of sex when you're diagnosing things is so important.

Tamil: 47:10

A few more of those. I could throw them out there. So because they're ones that are about, gender as well, right? Which is more about, how people present their symptoms and then what is the communication like between healthcare providers, and women or men and the kinds of assumptions that we bring, the unconscious biases that we bring into those conversations. So there's an amazing research from Ontario that talks about knee replacement surgery. And what was found was that physicians gave. Lower quality information to make informed decisions to women than to men. So they gave better information to men and they were less likely to refer women for knee replacement surgery. So orthopedic surgeons were 22 times more likely to refer men than women for knee replacement, regardless of the actual clinical case.

Sabrina/Mathilde: 48:24

Geez. Yeah. That's crazy.

Tamil: 48:28

So there can also be gender barriers to accessing care over and above sex.

Sabrina/Mathilde: 48:35

Yeah, I think there's such an important interaction between sex and gender in the way that we interact with healthcare and the way that healthcare providers interact with patients. Mm-hmm. So that's such an important reflection. Yeah. And even when you go back to hysteria that we talked at the beginning, just, I know a lot of people that go to their doctors and they talk about symptoms that they have, but they're not gonna do necessarily more tests because they associated with, um, some symptoms of your menstrual cycle, basically. Yeah. Which is very interesting. 'cause sometimes you need more, more testing and it's maybe not normal. Yeah.

Tamil: 49:13

I think that normalization of, women's pain or not taking women seriously about the pain they report is. Big problem in, in our society, and it could be menstrual pain or other kinds of pain. So women are less likely than men to receive painkillers in the emergency room, for example. And then this kind of normalization of menstrual pain is one of the things. I mean, there are many reasons, but one of the things that contributes to it, taking on average about five to seven years to get a diagnosis for endometriosis because that pain is normalized both by women themselves and then when they do start to seek a diagnosis with healthcare providers, it seems by healthcare providers also. So it's a really great point.

Sabrina/Mathilde: 50:04

Yeah. Yeah. Do you have any other examples you wanna share before we move to our conclusion? I love these examples. They're like priming me up.

Tamil: 50:13

So I'll take a simple example around some new kinds of pain medications that are being developed, which they work better if you only have one X chromosome than if you have two So if you're male rather than female. These medications are more effective. But that's really problematic because when we look at who is experiencing chronic pain in Canada, 60 to 70% are women. And we only know that the medication works better in males than in females because researchers were exquisite in doing sex-based analysis. So they designed their studies and they looked at the data to be able to understand differences between the sexes. And in the vast majority of health research that's happening more than 80% as far as we can tell from looking at the published abstracts from Canadian Institutes of Health Research, that is not happening. So we need more work. We're also not paying attention to the health conditions that have the biggest disease burden for women. Migraines, for example, menopause. Whereas substance misuse in the United States, which affects more men than women, this gets more money invested in it. So those are all questions that we, we need to, you could, you could throw a dart, almost any health topic that you threw a dart at, there's a need for more female and women specific research in that area. just in terms of the overall health status of women, compared to men, because of lack of sex specific health research, it results in poor health for women, delayed diagnosis at less effective treatment and more adverse events. So women live 25% more of their lives in poor health than men do. So it's true that women live longer than men, but women live a longer period of time with morbidity with ill health than men do. On average women experience a four year delay in receiving a diagnosis as compared to men, which is interesting when we talk about diagnostic tools. And speaking about heart health, again, women are seven times more likely than men to have a heart condition misdiagnosed or be discharged, during a heart attack. Wow. Good examples. Mm-hmm. Sad examples. And you know, we can hope that we're gonna progress in the right direction with all the research happening now, but I think it's so important to reflect on where we are right now and where we need to go with all that information. Yeah, maybe we can, wrap up by asking you just a few questions. In your opinion, what do you think are the priority gaps that we need to fill in research, but also maybe more into the medical sides? I think that the most important thing to improve the quality of care that people receive with the knowledge that we have now is. This is for all people across the board. And this is really to work towards patient centered and respectful care, right? So that people are not discriminated against or biased against, or not taken seriously because of their sex. They're gender, what they look like, what the unconscious bias is towards them in society. So as healthcare providers and as institutions, we need to do a better job. And that includes also providing trauma-informed care and creating trauma informed institutions so that we can provide better quality care. That will be the first thing, and that will not. Just help women, trans and non-binary people, it will help everyone to have a better experience in the healthcare system. The second thing is we just need more investment in women's health research across the board. Currently, our public funders are only dedicating 7% of research to women specific female specific topics, and that's just unacceptable given that we are half of the population and we have this huge historical backlog of research questions to answer because our current evidence-based is mostly based on men's body or men as the norm. And so to catch up and do better, we just need more investment across the board and we need accountability from researchers. So we have a policy in Canada that when you apply for a grant, you explain either why sex and gender aren't relevant. Or you explain how you're taking them into account in your research proposal where when the research is done, we need those results, analyzed by sex and gender to be reported out so that that information can make a difference for those clinical guidelines for diagnosis and treatment.

Sabrina/Mathilde: 55:39

Yeah, no, I think that's beautiful. Kind of somewhat call to action, but just recognition of where we're at and where we need to go. Mm-hmm. What can you tell us, just kind of reflecting on the conversation we've had today about, why it's important to think about the history of women's health in order to get better at advocating for women's health nowadays.

Tamil: 56:00

Sometimes, looking back in history, it makes it really obvious to us how the social norms or the social constructions at that time, are different from they are now, and how they shaped the care or shaped the social relations, the power dynamics at that time. And so looking at history can also make us critically appraise what our situation is today and understand those same kind of social norms and social dynamics that are potentially driving poor health in the present. And so we can become more aware, I think, by understanding our history.

Sabrina/Mathilde: 56:46

Okay. Yeah. Great answer. Final question. What's one change that you hope to see in women's health in the next 10 years? So, very big question.

Tamil: 56:58

Wow. Um, there are so many changes that I want to see in women's health in the next 10 years, and I think that many of them are on the horizon. but I'll mention a few. I know you only asked me for one, but, I want to see a non-invasive, diagnostic test for endometriosis. I think that we will have confirmatory testing, for HPV that people will be able to do at home within, within 10 years, I, am sure that in an even shorter timeframe will have universal no cost to people access to contraception across the country. Um, and I would like to see real advances in, treating, mental health challenges, for men and for women, both pharmacologically and in terms of the availability of talk therapy and other supports that this would actually be, accessible to people.

Sabrina/Mathilde: 58:14

Wow, that's, that's a powerful list. I love the ones you've chosen.

Tamil: 58:19

Not bad.

Sabrina/Mathilde: 58:21

No. Yeah. So we have 10 years for all of that. We can, we can do it sooner if possible. Well, I think we can wrap up on that. Absolutely. Phenomenal ending. We wanna thank you so much for joining us today, taking time out of your busy life and all of the important work you're doing to advance women's health research and care. Thank you so much for joining us today.

Tamil: 58:44

It was an absolute pleasure.