Alexandra Kautzky-Willer is the European pioneer of gender medicine. In her opinion, gender needs to be considered in order to provide more equitable diagnoses and treatments.

Women are more likely to die after a heart attack. But men are more likely to die from Covid-19. Understanding these differences is the goal of gender medicine.

This young discipline, which began in the 1980s in the United States, is still unknown to many. As a result, most medicines are still generally tested on men, even though we know that men's bodies function differently than women's bodies. Austrian researcher Alexandria Kautzky-Willer – who became the first European head of this discipline in 2010 – helps us understand the challenges of this still largely misunderstood science in Francophone countries.

IN VIVO How do you define gender medicine?

AKW / Gender medicine focuses on the biological differences between men and women and the consequences of those differences in regards to disease development and efficacy of treatment. Since the 1980s, several studies have shown that a treatment tested on a man does not necessarily have the same effects as it does on a woman. Similarly, some pathologies develop differently depending on sex. But the discipline also includes gender, which is the social and cultural dimension of biological sex. More recently, gender medicine has also taken into consideration epigenetics, which is the impact of external factors – such as the environment, nutrition and lifestyle – on gene function. As researchers, we look at how these factors play out based on sex.

IV / What are the main differences between men and women that would explain the variation in efficacy for a certain medicine?

AKW / The activity of enzymes – the proteins that regulate chemical reactions in the body – vary enormously between a male body and a female body. For example, men have faster digestive processes because their bodies produce more bile, which eliminates nutrients more quickly in the stomach. Similarly, women have slower metabolic activity in the liver and kidneys. Male bodies contain more water, which means that water-soluble medications, such as certain hypertension drugs, are more effective. Women have more body fat, which allows their bodies to store liposoluble medications, such as psychotropic drugs, for longer periods of time.

IV / What concrete consequences were observed?

AKW / Aspirin is more effective at preventing a stroke in women, and a heart attack in men. But studies have shown that women are 1.5 times more likely to experience side effects from a drug than men. So with aspirin, women are at higher risk of bleeding. Overall, these risks apply to the majority of drug categories and each medical discipline. Here’s another example: new diabetes treatments can eliminate large amounts of glucose through urine, which reduces blood sugar levels, as well as weight and cardiovascular issues. But for women, glucose results in a higher risk of developing vaginal yeast infections and even hyperacidity that can be fatal in rare cases.

IV / What role do hormones play?

AKW / The understanding of how oestrogen and testosterone work in the human body is essential for gender medicine – these hormones determine biological sex. But it's also important to understand that the activity of these two hormones, which are found in both sexes, is very complex. Furthermore, the oestrogen-testosterone ratio varies throughout the course of a person's life: in the uterus, there are many differences between girls and boys. They fade at birth and then become important again at puberty. Starting at menopause, women have more masculine hormones than feminine hormones, which leads to increased risk of developing cardiovascular diseases, almost at a similar rate to men.

IV / But oestrogen activity also seems to be beneficial for women...

AKW / Absolutely. These hormones allow women to have a better immune system than men. For example, the female body is better protected against viral diseases, because it develops more antibodies and T lymphocytes. Studies are underway to further understand the causes of these biological advantages that women have.

IV / Social factors also play a role, as we’ve seen with Covid-19.

AKW / With Covid-19, we saw that men were more likely to develop a serious case of the virus or die from it. However, this phenomenon cannot be explained by biological factors alone, given that women are more exposed to the virus than men are. In Western countries, women make up 70% of the nursing workforce. Behaviours also likely play a role. For example, several studies showed that women are more likely to comply with guidance from authorities, such as social distancing. Another issue is access to testing: one study showed that women in countries that promote gender equality had greater access to testing. Covid-19 is a good example of the complexity of issues that gender medicine tries to address.

IV / Starting in the 1990s in the United States and Europe, it is required to include women in clinical trials. Why are there still so many sex-related differences in drug efficacy?

AKW / Currently, the average percentage of women in clinical trials is only about 35%. This is because the safety protocols are so stringent; any woman who wants to participate in a clinical trial must follow a strict protocol to avoid pregnancy. As a result, laboratories largely choose women who have already gone through menopause. However, the female trial results don't automatically apply to younger women because oestrogen levels are not the same, which explains the risk of side effects that some women experience.

IV / What about providing different dosages on medicine labels based on sex?

AKW / Right now, there is only one sleeping pill that has different doses for men and women. The United States Food and Drug Administration (FDA) made it a requirement. But the European Medicines Agency did not. So the fact remains: women take medicines whose doses are calculated primarily based on men.

IV / Since 2010, you are the head of the gender medicine unit at the Medical University of Vienna. What advancements have you seen in the field over the past ten years?

AKW / Certain knowledge discovered by the gender medicine discipline is now included in medical textbooks. For example, students learn that the symptoms of a heart attack are not necessarily the same for men and women. Unlike men who experience sharp chest pains, women often struggle to localise and describe their symptoms, which makes the diagnosis more difficult. This is why women are more at risk of dying following a heart attack compared to men, as shown in a US study published in 2016. Another example: we now know that tumours that cause colon cancer develop more often in the right part of the large intestine in women (in men, they are often in the left part, which is more easily accessible). But generally speaking, this sex-specific knowledge is not yet applied enough in medical practice. We have a long way to go.

IV / In recent years, there has been increased recognition of gender issues in the public sphere. What is the perspective of gender medicine in this context?

AKW / To understand the perspective, it's helpful to know that this discipline began as part of the women's rights movement that developed in the 1980s. The idea was to improve health conditions for women, who were considered disadvantaged compared to men. Since around the 2010s, gender medicine has sometimes been criticised by social sciences for focusing too much on the biological differences between the sexes. There is somewhat of a trend to “deny” these differences in order to concentrate more heavily on gender. My position is clear: biological differences between men and women exist and they need to be taken into account in a medical context. But in no way does that exclude other issues relating to gender, such as intersexuality or transexuality. In Vienna, we studied the impact of hormones of the opposite sex in transgender patients. The goal of gender medicine is to create a more equitable and more individualised medical practice for everyone. /




Alexandra Kautzky-Willer is a professor of gender medicine at the Medical University of Vienna since 2010. Her research focuses on a better understanding of hormone activity (endocrinology) and diabetes in order to better treat the disease based on the sex and gender of patients.