One size fits… male?

Patient and doctor

‘Man-flu’ memes and the celebration of women’s endurance hide the reality that the medical world routinely downplays women’s pain and disease. Miriam Calleja takes a closer look.

We often hear that women are more tolerant to pain than men. Many are also proud of it. However, in the famous game-changing paper titled ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’ the authors Diane E. Hoffman and Anita J. Tarzian found that contrary to popular belief, women report more severe levels of pain, more frequent pain, and pain that lasts longer than men’s. Three Maltese women found out the hard way that confiding in medical practitioners does not always lead to help.

Culture and gender frame our behaviour around pain perception. Boys were, and some still are, told not to express pain by crying or showing emotion. Girls were told to calm down and not make a fuss. Pain meant weakness. Our language lacks the vocabulary to adequately describe pain. In ‘On Being Ill’, Virginia Woolf writes: ‘English which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache… The merest schoolgirl, when she falls in love, has Shakespeare and Keats to speak for her; but let the sufferer try to describe a pain in his head to a doctor and language at once runs dry.’

Gendering pain

By analysing a number of studies, Hoffman and Tarzian found that women are ‘more likely to be treated less aggressively in their initial encounters with the healthcare system until they prove that they are as sick as male patients.’ This is a phenomenon known as the Yentl Syndrome. In other words, doctors may brush female pain off as fabricated or exaggerated. This can impact diagnosis, disease progression, and treatment plans delaying care and fueling mistrust.

Prescribing uterus removal when a woman was ‘rebellious’ may seem like ancient history, but that bias has not fully retreated. Until the early 1990s, women were mostly excluded from clinical research studies and trials in medicine. What we knew about the body, about disease, and about medicine was based on men. Drugs that didn’t work on men, but might have worked on women, were discarded. With incomplete data, the medical world may have lost opportunities to improve women’s health. Have today’s healthcare professionals been trained to counter this gender bias? 

Another doctor later referred Karen for an MRI, and the tumour was detected a life or death analysis.

Antonia* doubts that. As a teenager she developed digestion problems and nausea every time she ate. When she complained, her family doctor downplayed the problem and suggested that she should just stop eating for a couple weeks. After this shocking response she ignored the issue for a long time, suffering in silence. Another doctor chalked it down to ‘growing pains’ and did not recommend a colonoscopy, even though Antonia asked for it.

Having received no satisfying response from her visits to medical professions, Antonia decided to do her own research, discovering that her symptoms matched the description of a condition called Crohn’s. Because of her constant discomfort and pain Antonia had no choice but to persist until she was granted testing and the correct treatment after years of suffering. This means that two doctors would have left her inflamed digestive system untreated, risking further damage.

Illustration by Gabriel Izzo

‘It is just a phase’

Women are often told that their ailments are due to stress or other emotional factors. A little rest would solve the problem; it is just a ‘phase’. Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests (see e.g. Samulowitz et al. 2018 study and numerous articles in the New York Times, The Atlantic and elsewhere). Thankfully, there are enough doctors who look beyond textbook-like symptoms. They make it a point to listen and investigate as much as necessary. Yet the burden of finding a practitioner ready to listen lies with the patient.

Karen visited her gynaecologist complaining of headaches and substantial weight gain. Test results revealed a high prolactin level, which is normally produced during pregnancy or right after giving birth. Yet when Karen asked to be referred for an MRI to investigate for tumours in the pituitary gland, the doctor refused, telling her that she was ‘making a fuss’. Another doctor later referred Karen for an MRI, and the tumour was detected a life or death analysis. 

Some doctors would call a woman insisting on referral for further testing a hypochondriac, even in the presence of positive clinical tests.

Gynaecologists feature often when discussing gender bias. Without systematic training to counter biases, women are left to ‘shop around’ for a gynae that doesn’t shame them or belittle their wishes. This is surprising for a profession specialising in women’s health. 

Reproductive issues open another can of worms. Some women who decide not to have children are treated as though they don’t know what they’re doing. Their doctors imply that the patient will inevitably change their mind, or try to guilt the patient into considering the feelings of a hypothetical man they might meet.

You would think that commitment to bear biological children would be respected, but women who undergo IVF are often treated with insensitivity too. Sandra* and her husband had a harrowing story to tell me. Sandra’s gynaecologist decided to immediately hurry her to IVF after the first visit about their concerns at not being able to conceive. The gynaecologist was rarely present for her many appointments at hospital, leaving Sandra to be passed from one doctor to another, internally examined by various doctors without explanation or prior request for consent. With the exception of one doctor, none of them introduced themselves. All along she tried to ask questions, but was kept in the dark about the situation, going along with the doctors’ instructions but losing trust. The outcome of the first procedure was unsuccessful, and because of how traumatising all this felt, the couple decided not to try again.

Unlearning the bias

Pain is subjective and difficult to measure. An individual’s tolerance to pain is affected by various factors, and pain perception may change with time and experience. Pain causes distress, which makes it difficult to measure objectively. So how can overworked doctors make the best possible assessment?

In her thesis titled ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals’ (University of Malta, 2008), Maria Campbell studied pain perception in other healthcare professions in Malta back in 2008, finding out that outdated attitudes have not been challenged. She writes, ‘Incomplete knowledge, outdated attitudes, myths, and misconceptions about pain and its management contribute to unsafe, inadequate, and inappropriate pain management.’ Medical practitioners wanted to be more up-to-date: ‘The need for information in the form of leaflets, seminars, and continuing education was echoed in the overall answers (90%) of the close-ended question and in the statements declared by participants.’ But before this training becomes systemic, the radical act of listening to women is a good place to start. 

* Name has been changed

Further reading:

Fassler, J. ‘How Doctors Take Women’s Pain Less Seriously’. The Atlantic. October 2015.

Hoffman D.E., Tarzian, A.J. ‘The Girl Who Cried Pain: A Bias Against Women In The Treatment Of Pain’. Journal of Law, Medicine & Ethics, Vol. 29, pp. 13-27, 2001.

Campbell, M. ‘The Chronic Pain Management Service: Awareness and Perceptions Among Healthcare Professionals.’ University of Malta. June 2008. 

Making it in a male-dominated world

Scales of equality

Seeking a job and growing in it may seem like a commonplace thing nowadays. Yet for women at the top of their game today, the path was fraught with hurdles and required the utmost determination. THINK takes a moment out of the incredibly busy lives of three central women at the University of Malta (UM) to discuss their life stories and challenges quashed. Words by Martina Borg.

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Rejecting apathy at all costs

Rejecting apathy

Now an unwavering campaigner for women’s rights, lawyer Dr Lara Dimitrijevic tells Teodor Reljić about how the academic community’s action, inaction, and reaction to injustice shaped her life and activism.

From hurdles in reporting domestic violence to Malta’s budding pro-choice movement, hardly any discussion on women’s freedoms goes by without a word from family lawyer Dr Lara Dimitrijevic. Recently nominated for the US Secretary of State’s International Women of Courage Award, Dimitrijevic represents mistreated women in court. She has also founded vocal NGO Women’s Rights Foundation, which trains police enforcement, the judiciary, social workers, lawyers, and activist organisations to treat victims of gender-based violence fairly. 

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Voices for freedom and choice

Author: Dr Alexander Clayman

Dr Alexander Clayman

Abortion is a criminal offence in Malta. This means Maltese women who wish to end their pregnancy have severely limited choices. Those more affluent can pay to terminate their pregnancy abroad. Those who do not have the money can either continue the pregnancy against their will or terminate locally under unsafe conditions, risking both their health and freedom. 

Any woman who undertakes an abortion potentially faces three years in jail. Anybody who assists, such as a doctor, could also be sentenced to four years behind bars. This flies in the face of best medical practice which states that safe abortion services should be accessible to women who need them. 

A few weeks ago a group of doctors, including myself, came together to set up Doctors for Choice Malta in order to advocate for sexual and reproductive health. This includes comprehensive sex education (NOT abstinence-only education) and access to free contraception (condoms, pills, and intrauterine devices). Increased use of contraception alone results in fewer unwanted pregnancies and subsequent abortions. Putting contraceptives in the hands of comprehensively sex-educated individuals can do even more. This said, abortion still needs to be available to those people who need it. 

As a doctor, I feel I have a duty to use my knowledge and skills to better my community’s health. Together with Doctors for Choice, we are basing our efforts not on opinions or morality, but on years of medical and sociological research which shows that sex education, contraception, and accessible abortions make a society healthier. 

The irony was not lost on me when comments accusing me of being a baby-killing-mad-axe-murderer-who-doesn’t-understand-what-a-real-doctor-is started rolling in. Luckily for me, forewarned is forearmed, and the negativity failed to penetrate very deep. 

What did strike me was the contrast between the way people communicate their derision and their support. Abusive comments come in fast, prominent, and loud. Supportive comments are usually sent in private. At present, it’s clearly very easy to be openly anti-choice, but very difficult to be openly pro-choice. 

To those afraid to raise their voice and speak the truth, I say: whatever dogma, tradition, or a battalion of angry keyboard lieutenants might tell us, those who advocate for reproductive choice have nothing to be ashamed of. We are on the right side of history. 

Read more: Marston, C., & Cleland, J. (2003). Relationships between Contraception and Abortion: A Review of the Evidence. International Family Planning Perspectives, 29(1), 6. https://doi.org/10.2307/3180995

Stanger-Hall, K. F., & Hall, D. W. (2011). Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S. PLoS ONE, 6(10), e24658. https://doi.org/10.1371/journal.pone.0024658

Can the EU empower women in Afghanistan

The European Union’s success relies on positive relationships—cooperation and good will is key. The EU’s Development and Cooperation Policy exists to support these connections. Its focus is on external relations, establishing partnerships with developing countries and channelling billions of euros to them every year. The European Commission plays a crucial role in this regard, managing and implementing directives on behalf of the EU. But what do we really know about the effectiveness of EU aid in helping citizens in developing countries? And how far is female empowerment part of this agenda? 

In short—we don’t know much! 

Research in this area is scarce, and this is what prompted me to tackle this question myself, under the supervision of Dr Stefano Moncada. My specific focus was on assessing whether the EU is committed to gender equality and female empowerment, taking Afghanistan as a case study. I reviewed all the available aid programming documents from the last financial period, and assessed whether the EU was effectively supporting Afghanistan to achieve the fifth Sustainable Development Goal (SDG) of gender equality. I adopted a mixed-method approach, using content analysis and descriptive statistics. Basically, this meant coming up with a very long list of keywords related to gender, and checking how many times these words appeared in the policy documents. Whoever invented the ‘ctrl + F’ function saved my academic life! 

Rebecca Zammit

The results of my research were pretty surprising. I found that the EU is now focusing much more on gender empowerment on the ground in Afghanistan than it did a few years ago. 

According to my data, and when comparing this to previous studies, it appears that the EU’s commitment to supporting this goal is growing over time. However, I also found that there is substantial room for improvement, as the attention given to such issues is rather conservative, and not equally balanced across all the SDG targets. For example, the need to increase women’s employment is mentioned many more times than the need to support female education or political participation. This is surprising as education is key to many other improvements in wellbeing. Nevertheless, I believe the overall results are encouraging and important, not only to highlight improvements in the effectiveness of the EU’s development and cooperation policy, but also in reply to a growing sentiment that puts into question the EU’s capacity to manage, and lead, in key policy areas. We can only hope that this continues exponentially. 

This research was carried out as part of a Bachelor of European Studies (Honours) at the Institute for European Studies, University of Malta. The dissertation received the ‘2018 Best Dissertation Award’.

Author: Rebecca Zammit

Women in science, do it with art

STEM subjects tend to intimidate, seeming inaccessible to the untrained eye. Dr Vanessa Camilleri, Dr Marie Briguglio, and Prof. Cristiana Sebu speak to Becky Catrin Jones about how they are challenging preconceptions by combining science and art at Science in the City, Malta’s national science festival.

It’s 2018. We live in a world where saliva samples sent out from the comfort of our own homes return to us with a sprawling outline of our ancestry and where some of the biggest social media influencers are robots. Despite this progress, utter the word ‘scientist’ and the outdated image of men in white lab coats still abound.

When advances in STEM (Science, Technology, Engineering, Mathematics) direct almost every aspect of life, why is it that so many still switch off the minute we mention science?

Researchers haven’t always had the best PR. In films and TV, science is often portrayed as a foreign language, gibberish to most. Real life is not always that much better, with some researchers needing to carry a jargon-busting dictionary around to translate what they study. To improve its reputation, we need a more creative approach that can break these stereotypes and bring science to the masses in a way that doesn’t send people running for the hills.

Science in the City (SitC), Malta’s science and arts festival, is the perfect opportunity for researchers at the University of Malta (UM) to bring their research to citizens in a way that doesn’t need subtitles.

Prof. Cristiana Sebu

Professor Cristiana Sebu (Department of Mathematics, UM) joined UM only three years ago, but has already made a firm mark. With a background in Applied Mathematics, she moved to the university as an Associate Professor, setting up a new course stream for undergraduate students in Biomathematics. Sebu’s interests lie in the practical applications of mathematics, particularly in biology, and in exploring how mathematics underpins essentially everything in life. ‘The links between mathematics and biology are strong,’ Sebu asserts. ‘We need to be able to make predictions and apply mathematical modelling to understand complex and intertwined biological systems such as signalling pathways in the body or ecosystems in the environment.’

That said, Sebu is still very aware that her love for mathematics is not often shared by the wider world. The word ‘mathematics’, however applied it might be, still strikes fear into the hearts of many. In an effort to counter this reaction and replace it with a more positive one, Sebu is joining the myriad of researchers at SitC and adding music to the mix.

‘Maths provides the building blocks and the structure of music,’ says Sebu. ‘Debussy, Mozart, Beethoven, and so many more used a mathematical pattern known as the Fibonacci Series in their scores.’ The Fibonacci sequence is an infinite pattern of numbers where the next number is the sum of the two previous ones, going from 1, to 1, 2, 3, 5, 8, where (1+1) = 2, (1+2) = 3, and so on. This sequence is closely related to what’s known as the Golden Ratio, an infinite number which can be found in so many examples throughout nature, from the composition of bee colonies to the shape of seashells and the patterns in sunflower seeds.

Debussy, Mozart, Beethoven, and so many more used a mathematical pattern known as the Fibonacci Series in their scores.

To highlight this elegance, Sebu has teamed up with jazz composer Diccon Cooper. The performance, entitled ‘Jazzing the Golden Ratio’, will feature presentations of the Golden Ratio in art, the environment, and the human body, accompanied by Fibonacci-inspired jazz music specially commissioned for the festival. Sebu herself will also be there, sharing her thoughts about the significance of this pattern in the world around us. ‘People see arts and science at odds, but the two are very much embedded in each other,’ Sebu states. ‘Hopefully we’ll be able to demonstrate the beauty of mathematics at Science in the City this year.’

Dr Vanessa Camilleri

The significance of this connection between arts and science is a notion shared by Dr Vanessa Camilleri (Faculty of ICT, UM). After working on a project combining Artificial Intelligence (AI) with behavioural studies at Coventry University, Camilleri found a niche research environment using immersive technology and design to influence our decisions and behaviours. Returning to the UM, she worked on a Virtual Reality (VR) headset allowing teachers to experience what it might be like for a child with autism in a classroom.

‘Unless you experience something, it’s very difficult to reach a deep level of empathy,’ Camilleri said of the idea behind the project. ‘We wanted to give [teachers] the opportunity to build new memories through VR, and help them understand the needs of the child in greater detail.’

For SitC this year, Camilleri is taking a different approach. The VR headsets are having the night off, and attendees will need nothing but their smartphones to see science brought to life in artistic form. Using Alternative Reality (AR) methods, she’s collaborating with artists Matthew Attard and Matthew Galea to bring a fourth Triton to the fountain for one night only through a project funded by Valletta 2018. By downloading the smartphone app, attendees will see the new fountain brought to life through their phones. In the build-up to the festival, the artists are using eye-motion tracking and heat mapping sensors on volunteers to see which bits of the current statue draw their attention. This is then translated into the final depiction, making the fourth Triton as eye-catching as the current three.

Prof. Cristiana Sebu

Lecturer Dr Marie Briguglio (Faculty of Economics, Management & Accountancy, UM) is also hoping to use art to bring her subject to life, albeit in a more sober manner. As a behavioural economist, Briguglio’s focus is on a population’s impact on environment and how we can police this. In particular, at SitC, she wishes to convey the ‘Tragedy of the Commons’—the notion that free or common assets such as public space or air are likely to be exploited by the masses due to sense of entitlement combined with lack of responsibility.

To do this, Briguglio recruited the expertise of Steve Bonello, a cartoonist with a political bent. ‘Working out how best to design environmental regulation underpins much of the research I am involved in. But it’s also very evident in many of the cartoons Steve draws,’ says Briguglio. ‘I soon realized that there was enough material to write a book.’ And so they did, combining the work of faculty with cartoons to produce the comic The Art of Polluting.

Home truths about how we personally damage the world we live in might not make for easy reading, but Briguglio hopes the fusion between arts and science will make this message easier to swallow. ‘It is intended to bring to light research on environmental pressures, status, and responses in a manner that is accessible and also fun.’ The book itself will be displayed as part of a larger instalment titled No Man’s Land, which will include a live action play, more detailed research, and even a free tree-planting stall.

Putting research on the main stage is no new concept to any of these three, and this year’s SitC is certainly not their first venture into science communication. The projects they’ve put forward have all stemmed from previous public engagement ideas. Camilleri worked with the same artists on an AR feature about Greek Mythology, and she regularly translates her research for mass media. A science communication event, Go For Research, which was spearheaded by the Faculty of Science and Directorate of Curriculum Management and aimed at the Junior Science Olympiads was where Sebu’s idea for highlighting the beauty of mathematics was born.

The passion for their subjects is infectious in all three researchers. Each one listed the prospect of inspiring their audience as their top goal for the festival. Shaking up science communication by presenting it in a way we wouldn’t expect, through musical maths, theatrical economics, and artistic AI, provides an opportunity for researchers and citizens alike to see science through a new lens. One where progress seems brighter and kinder.

  Author: Becky Catrin Jones

Design

Prostitution no.2 by Abigail Attard Prostitution is known as the oldest profession. It is also the one with the highest human cost. This artwork reflects the pain female prostitutes feel contrasted by the coldness of the men who fuel the business. Attard was inspired by news items on these issues, and her belief that more measures are needed to bring an end to the business that fuels the objectification of women.
Prostitution no.2
by Abigail Attard
Prostitution is known as the oldest profession. It is also the one with the highest human cost. This artwork reflects the pain female prostitutes feel contrasted by the coldness of the men who fuel the business. Attard was inspired by news items on these issues, and her belief that more measures are needed to bring an end to the business that fuels the objectification of women.

 

CuriouSedative by Sharon McLean Many idioms reflect how curiosity is not always a good thing. This artwork personifies the mental struggle suffered when a curious mind tries to seek tranquility. It also represents a person’s cautiousness sheltering the self from exposing their state of mind.
CuriouSedative
by Sharon McLean
Many idioms reflect how curiosity is not always a good thing. This artwork personifies the mental struggle suffered when a curious mind tries to seek tranquility. It also represents a person’s cautiousness sheltering the self from exposing their state of mind.

 

Untitled 1 by Lara Gove This artwork is part of a series interpreting a text known as Cities and the Dead 4 which is found in Italo Calvino’s book Invisible Cities. The painting reflects a state of decay, an entire city turned into a burial ground with confined spaces with restricted movement.
Untitled 1
by Lara Gove
This artwork is part of a series interpreting a text known as Cities and the Dead 4 which is found in Italo Calvino’s book Invisible Cities. The painting reflects a state of decay, an entire city turned into a burial ground with confined spaces with restricted movement.

 

Wooden Sculpture no.1 by John Paul Muscat This artwork’s imagery reflects multiculturalism. It is the artist’s first wood carving.
Wooden Sculpture no.1 by John Paul Muscat
This artwork’s imagery reflects multiculturalism. It is the artist’s first wood carving.

 

Hollow by Nicolai Schembri Cyberbullying can have dreadful repercussions. This art installation with figures made of transparent tape reflects the emptiness a person can feel when they are the victims of online harassment. The figures merged with their surroundings and became part of the space, with an almost ghost-like effect.
Hollow
by Cristina Formosa
Cyberbullying can have dreadful repercussions. This art installation with figures made of transparent tape reflects the emptiness a person can feel when they are the victims of online harassment. The figures merged with their surroundings and became part of the space, with an almost ghost-like effect.