American physicians’ understanding of health was based around the male body, while diagnoses for mental health disorders were based around symptoms experienced by women — a history that still haunts health care today.
Men as a standard, women as a deviation
In the 18th and 19th centuries, American doctors used a very specific type of person to build their understanding of physical health.
“The standard body was really a white male body of a certain size. So the 70 kilogram man was sort of the standard, and everything else was a deviation from that,” said Laura Hirshbein, vice president of the American Association for the History of Medicine. “And the assumption was that if you just focused on that, that would tell you everything you needed to know about physiology and biology — except for reproduction — and that was where women were different.”
In clinical trials, drugs to lower blood pressure, lower cholesterol and manage diabetes were almost exclusively done on men until the 1990s, when an office with the Food and Drug Administration and Health and Human Services pointed out the lack of information about women in these clinical trials.
Hirshbein, who was in medical school in the ’90s, said she and her peers learned about medicine in stereotypes. For example, an encyclopedia of illustrations to educate medical students depicted a heart attack with an image of a man coming out of a pub with a cigarette and a suitcase, while clutching his chest and dropping things from his left arm.
“It was a kind of a revelation to many of us who were trained in the '90s and early 2000s that heart disease is actually extremely common in women, and it looks different,” she said. “We didn't learn the classic way it presents in women. We learned the classic way it presents in men.”
The focus on reproduction as the main “deviation” from men has led to inaccurate beliefs about how women’s reproduction impacts their body.
“People sort of assumed that their reproductive hormones were protective,” Hirschbein said. “And there's still very much an assumption women's reproductive hormones are what keep women from having heart attacks, which has led to the assumption that women just need more hormones, which turns out, is not quite accurate.”
A 2019 study of health data from 6.9 million Danish patients found that women are diagnosed four years older than their malecounter parts on average, across hundreds of conditions — this despite the fact that women are more likely to go to the doctor when they first experience symptoms.
Drug trials on female patients develop diagnosis criteria
Conversely, women were the ones who set the standard for mental health diagnoses. That history still impacts how doctors expect mental illnesses to present and can cause men to be underdiagnosed with conditions like depression.
For most of the 20th century, mental health care was conducted in state mental hospitals. Most of the patients were women, since mentally ill men were more likely to end up in prison or be looked after at home by female caretakers. When psychiatric medications were being developed and tested, pharmaceutical companies partnered with physicians working in state mental hospitals, where the new drugs were tested on the mostly female patients.
“Prior to 1980 there were no criteria for major depressive disorder,” Hirshbein said. “There were actually no criteria for any specific psychiatric disorder. That was all created with DSM-III, that was published in 1980. And so the trials of medications that became known as antidepressants, those trials actually helped construct ... what the what the diagnosis of depression was.”
According to the DSM-III, patients experiencing depression will endorse feeling sad, difficulty concentrating, a lack of motivation and guilt.
Derek Griffith, chair of Global Action on Men’s Health, said depressed men are less likely to report being sad, but they will describe being irritable, having angry outbursts or increasing substance use.
“Typically, men are diagnosed with depression at about half the rate of women. When we included those types of symptoms, we actually saw the gender gap go away,” Griffith said. “We know that given men's rates of substance use, dying by suicide and related factors, that there's something that we're missing in how we identify men who are in need of support, services and attention, and it's not being captured by the way that we're diagnosing men with particularly mood disorders, but mental health issues in general.”
According to the National Institute of Mental Health, women are more likely to have suicidal thoughts than men, but men are four times more likely to die by suicide than women.
“My understanding is that women may make more gestures and efforts to show that they are in need and distress at a level where they're thinking about these issues,” said Griffith. “Men tend to use more lethal means and therefore are more likely to die from those efforts.”
He added men’s roles in society are changing, as they fall behind women in education and experience job market shifts.
“We're not as clear about what is our role in a family, if it's not to be the provider. And so that has left some having somewhat of an existential crisis, if you will, about what exactly are we supposed to do in families and so forth,” Griffith said. “And so it's not something to suggest that we should go backwards, but it is to say that we have to pay more attention to understanding how men are supposed to adapt, evolve, grow in this next phase of our society.”
To hear this conversation listen to Unsettled, hosted by Charity Nebbe. Caitlin Troutman produced this episode.
