Are Women Treated Differently After Stroke?
Jocalyn P Clark, MSc, PhD candidate
Department of Health Sciences,
University of Toronto and
The Centre for Research in Women's Health,
Toronto, ON.
Stroke is the third leading cause of death for North American women and the leading cause of long-term disability in Canada. According to the Ontario Ministry of Health and Long-Term Care, in 1994/95 stroke-related costs in the province totaled $857 million. The Canadian Stroke Network estimates annual costs for stroke in Canada to be 2.7 billion dollars. Over the next five years the incidence of stroke is expected to increase by over 30%, and those figures could jump to 68% within two decades. Every year among women, stroke claims more than twice as many lives as does breast cancer. Indeed, according to Dr. Beth Abramson, a cardiologist at St. Michael's Hospital in Toronto and an expert in women and stroke, "The issue of stroke in women is a significant one. This is due to potential bias in treatment of female stroke patients, but also to the greater co-morbidity and health care costs associated with treating women when they suffer from stroke."
Like other cardiovascular conditions, stroke in women is highly age-dependent: women are, on average, several years older than men when they suffer their first stroke and tend to be sicker. Owing to this age dependence, the health burden of stroke will only magnify as the proportion of elderly women in the population increases over time. When considering the proper treatment of stroke and whether gender differences exist, the relationship of gender with age is crucial to our understanding. On the one hand, the gender-age interaction complicates clinical decision-making and potentially explains why physicians under-prescribe stroke interventions to older, more frail women. On the other hand, it suggests that a "double-disadvantage" bias (see Geriatrics & Aging, Volume 1, Number 3) persists, compromising the treatment, health and well-being of female stroke patients. Unfortunately, very little research on stroke treatment and women is available, although general trends in cardiovascular disease treatment provide some clues.
Gender Bias in Cardiovascular Research and Treatment
There is a great deal of support for the belief that gender bias in cardiovascular research and treatment exists. Traditionally, research on heart disease has been conducted on men; therefore, the knowledge base on women's experience, symptoms, treatment and prognosis following cardiovascular events is lacking. According to the American Heart Association, symptoms such as chest pains in women were often attributed to non-cardiac causes by clinicians and patients, leading to a under-recognition of their conditions. Diagnostic tests and procedures were seen as being less accurate in women than in men, so clinicians may be reluctant to use them or misinterpret results. In terms of gender bias in treatment, sex differences in therapeutic and surgical management (e.g., coronary artery bypass) have been well established and these persist after adjusting for age and other potentially confounding factors. More recently, however, efforts have been made to counteract the historical male bias in cardiovascular research and treatment. For example, policy recommendations supported by the Heart and Stroke Foundation and published in the January/February 2000 issue of the Canadian Journal of Public Health/Revue Canadienne de Santé Publique promote a gendered approach to understanding cardiovascular disease prevention and intervention. In addition, the guidelines advocate the monitoring of the efficacy of medical management such as diagnosis, treatment and prognosis of heart disease and stroke in Canadian women. In spite of new directions in women's heart health research, stroke in particular has commanded very little attention. Remarkably, a discussion of gender or the particular needs of women patients is absent from