‘The second sex’
If you are a woman, the chances are you’ve felt othered at some point in your life. I encountered it in the gym again the other week: whenever I go to a new gym, I’m faced with machines not built for me—a non-disabled cis woman of average height. The machine handles are often too thick for me to use comfortably (women’s grasp and wrist strength ranges from 50-60% of men’s). My arms aren’t long enough to use the bench press comfortably, and my feet don’t touch the floor on some machines. Yes, I can buy wrist straps and use alternative exercises to sort this out (as my male friend kindly reminded me), but why should I have to?
“Why do women have to change themselves?”
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My gym gripe may appear trivial, but other male-default designs have more serious impacts on health and wellbeing. Simple everyday examples include seat belts which don’t sit comfortably across women’s chests and other car design flaws resulting in women being 47% more likely to be seriously injured, and 71% more likely to be moderately injured than a man. Other examples include Personal Protective Equipment, which makes going to the bathroom a major operation, and police body armour, which doesn’t protect women because it isn’t made to fit their bodies.
In 1949, French feminist and philosopher Simone de Beauvoir wrote, “The lives of men have been taken to represent those of humans overall”. This famous quote from her essay The Second Sex still perfectly encapsulates this feeling of ‘otherness’. From small design flaws that make you feel like this world isn’t quite made for you, to the glaringly obvious discrimination all over the world, women suffer at the hands of bad design and the systematic ignorance of their experience.
But what does this mean for health? In a world designed for men, does women’s health suffer? The short answer is yes. From more obvious discrimination to daily microaggressions, the systemic otherness of women materialises in poorer health outcomes.
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“In a world designed for men, does women’s health suffer? The short answer is yes.”
In almost all parts of the world, women have a longer life expectancy than men; in the United Kingdom (UK), women’s life expectancy at birth was 83 years, while men’s was 79 years in the period 2018–20. Yet women also spend over a quarter of their lives in disability or ill health, while the figure is only one fifth for men. These figures translate to women in the UK living with ill health or disability for over five years more than men, and this gap is widening. The reasons behind this disparity are multifaceted and wide-ranging. Some, however, are remarkably simple and, therefore, surely simple to fix.
Until recent years, there has been a prevailing perspective that the only difference between men and women is size: that women are just ‘small men’. This perception has resulted in women being vastly underrepresented in research, which has serious impacts on health.
A 2008 analysis of textbooks from some of the most prestigious universities in Europe and North America found that male bodies were used three times more than female bodies to represent ‘neutral’ body parts. Caroline Criado Perez’s 2019 book Invisible Women: Data Bias in a World Designed for Men shone a spotlight on the degree in which the world is manufactured for a male prototype. This assumption of female bodies being ‘essentially the same’ as male bodies persists to this day, and it is dangerous. Although studies have found female representation increasing over time, the trends are modest and unlikely to resolve the wide gaps in research. For example, examining the 25 most-cited cardiology articles each year between 1996 and 2015, the percentage of women included only increased by 0.29% each year, and still only sat at 32.2% of female participants in 2015.
“This assumption of female bodies being ‘essentially the same’ as male bodies persists to this day, and it is dangerous.”
Similar stories are seen with HIV research. Women represent almost half of HIV-positive adults in the world, yet within research conducted in the United States, women were represented in only 38.1% in vaccination studies, 19.2% participants in antiretroviral studies, and 11.1% in studies to find a cure. With these gaps, how can clinicians hope to understand why men and women have different experiences of HIV? A stand-out distinction, for instance, is that women are less likely to start antiretroviral therapy, often due to family commitments making appointments difficult, fears about pregnancy, or socioeconomic circumstances. Without accurate research, these simple features of a woman’s HIV experience cannot be addressed.
While gender differences in health research have only more recently entered public consciousness, the gender pay gap has had a longer history in the headlines. Worldwide, for every £1 a man makes, a woman only makes 77 pence, and, while this pay gap is slowly narrowing, the impacts of COVID-19 saw the forecast time taken to close the global gender gap increase from 99.5 years to 135.6 years.
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Globally, women do 75% of unpaid work (this includes tasks like housework and caring for children, relatives, and spouse’s relatives), spending almost triple the amount of time carrying out this work, often alongside full-time jobs. Yet, the work women do is fundamental to keeping the world moving; it is estimated that unpaid domestic and care work contributes between 10–39% of a country’s Gross Domestic Product and can add more value to the economy than the commerce, manufacturing, or transportation sectors.
Unfair and frustrating? Certainly. But how does this affect health?
Low control over one’s job and an effort-reward imbalance are known to increase stress, resulting in poorer health outcomes like heart disease and stroke. For women, whose ‘primary’ jobs are often unpaid care and work, one can see how the high effort and low reward would fit this model. Perhaps predictably, given the underrepresentation in research, there are few studies which look at how this model plays out for different genders, but those that do find poorer health outcomes for women.
Beyond the psychosocial effect of women’s unpaid work and its repercussions on health, having a lower income than their male counterparts results in health inequalities. Worldwide, women can expect to earn between 31 and 75% less than men over their lifetimes due to their unpaid work and other factors like inadequate maternity leave, male bias in pensions, and biased employment procedures. Wealth helps protect against life stressors. As women live longer than men, and are less able to accumulate wealth, it’s no wonder women spend more years of their life in poor health.
“Women can expect to earn between 31 and 75% less than men over their lifetimes.”
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What happens when being a woman intersects with other marginalised communities? When we consider this, de Beauviour’s quote could read: “The lives of straight, cis, white, non-disabled, young men have been taken to represent those of humans overall.”
While women are underrepresented in research, this is even more true for women of colour, older women, women of child-bearing age, those with disabilities, LGBTQI+ women, and those of lower socioeconomic status. For example, in nail salons, where the workforce is almost exclusively female and often migrant (a population who often lack access to regulatory and health systems), workers are exposed to dangerous chemicals for long periods of time—the effects of which have not been researched by dose. This is not a problem women of higher socioeconomic status contend with.
In the UK, black women are five times more likely than white women to die in pregnancy or childbirth; an inequality which should not be tolerated, yet the dual evils of misogyny and racism (misogynoir) hinder change. Shockingly, a woman I know going through menopause told me how her general practitioner believed white women experience worse menopausal side effects. Do black women feel less pain, or are they given less attention and socialised to complain less, lest they be marked as an angry inconvenience? Evidently, more research on the menopause and female reproductive health is needed, and the inclusion of black women’s experiences is urgent.
A promising sign that change may be afoot came on International Women’s Day this year, when the UK government began a call for evidence for its Women’s Health Strategy. Submissions were invited from the public, clinicians, researchers, and groups interested in women’s health. The hope is that the government is finally addressing the historic difficulties women have had in accessing appropriate and adequate healthcare. The challenge will be to make sure positive change is effected across all groups of women.
“The challenge will be to make sure positive change is effected across all groups of women.”
More broadly, artificial intelligence (AI) may play a part in driving change. We’ve seen that when AI is trained on data which doesn’t consider the female experience, it only expands inequalities. But perhaps the rise in Femtech (female technology, a term applied to a category of software, diagnostics, products, and services that use technology to focus on women's health) will provide a partial solution to this—most likely in the areas of fertility and fitness for which apps and devices are commonly designed, providing women with the knowledge and control of their bodies that they deserve. There are, of course, concerns about data sharing, and care must be taken not to profit from an individual’s data without consent. Additionally, there must be a recognition that data harvested in this way is not concentrated on only women with more social privileges.
Ultimately though, we need more women in positions of power and influence, from a diverse range of socioeconomic backgrounds and cultures, more women engineers designing our world, and a general shift in the default men mindset. Women make up half the world; let’s have them shaping it accordingly.
The author recognises that statistics and discussion on women’s and men’s health represent a (cis)gender binary, and do not fully encapsulate the experiences of transgender, non-binary, and folks across the gender spectrum. Along with Tamzin’s own reflections on women’s health, more voices from marginalised genders are needed to deconstruct the white, cisgender, able-bodied, male norm in health research and care.
