The International Society for Gender Medicine

History and Highlights

Marianne Legato J, Marek Glezerman, Marianne J. Legato

• Publisher: Academic Press
• Year: 2017
• Print ISBN: 9780128118504
• eBook ISBN: 9780128118511
• Topic: Biological Sciences
• Subtopic: Oncology
• Index: Biological Sciences

The International Society for Gender Medicine: History and Highlights is about a major step in the improvement of quality in medicine, namely the long overdue understanding that women are different from men in every system of the body and may require different approaches in diagnosis and treatment. This is not a textbook, nor is it a scientific publication. It is the story of the International Society for Gender Medicine (IGM) as soon through the eyes of 12 pioneers of Gender and Sex Specific Medicine (GSSM) from seven countries, five of whom were the founds of IGM in 2006. It describes the development of this new science in the respective countries and academic environments of the authors, their very personal experience while promoting, and implementing their vision of GSSM, their frustrations, successes, and achievements.The field of gender-specific medicine examines how normal human biology and physiology differ between men and women and how the diagnosis and treatment of disease differs as a function of gender and sex. Among the areas of greatest difference are cardiovascular disease, mood disorders, the immune system, cancer, osteoporosis, diabetes, obesity, and infectious diseases.This book is essential reading for all researchers, graduate students, practitioners, and anyone interested in this diverse and thriving field. From the early beginning, to the recent NIH mandate that females be included in pre-clinical as well as clinical research and that research results be reported by sex, the quick read will broaden your understanding of the history of the field and highlight where the future is headed.- Illustrates how major universities and organizations around the world concentrated first on the unexplored world of women's biology and then progressively adopted the larger view of the importance of investigating and comparing both sexes through all levels of biomedical research- Notes the recent NIH statement that funding would depend on inclusion of two sexes in scientific protocols wherever possible as an important affirmation of the legitimacy of gender specific science- Addresses challenges for the future: how to incorporate both sexes in investigative protocols in a scientifically valid way, and whether or not the cost of including two sexes in protocols will be prohibitively expensive- Dispels the idea that gender-specific medicine is women's medicine and how changing the name of most of the organizations currently advocating and developing gender specific medicine to include men and women (rather than just women) in their group name would help dispel this notion

Chapter 1

Gender-Specific Medicine

An Idea That Should Have Been Intuitive But Which Required the Efforts of an International Community to Establish

Marianne J. Legato^1,2, ¹Columbia University, New York, NY, United States, ²Johns Hopkins University, Baltimore, MD, United States

Abstract

This is my own perception of how gender-specific medicine began and eventually matured into an international discipline. My contribution to GSM was facilitated by several important collaborations, two of which I have described in detail here: one with the great American corporation, Procter & Gamble (supported at Columbia by Dr. Myron Weisfeldt), and the other with Dr. Vivian Pinn at the Office of Research on Women’s Health of the National Institutes of Health. Both stories were rich with new ideas and exciting input from both scientists and the lay public and were high points in my career. The stories of my colleagues in this book are rich with the tales of their own experiences, all unique stories and all portraying the courage, intelligence, and persistence necessary to make a new venture succeed and thrive. We are proud of what we have done and contend that the new science of gender-specific medicine has profoundly changed the nature of how we research the mechanisms of disease and care for our patients.

Keywords

Gender-specific medicine; coronary artery disease; memberships; Columbia; P&G

Writing a concise and interesting summary of my life in academic medicine and in particular about my role in establishing and expanding the new field of gender-specific medicine is not easy. I have read the other chapters in this book from the colleagues Dr. Glezerman and I have invited to tell their stories: each narrative is fascinating, unique, and deeply personal. I know most of these scholars quite well; I know about their struggles, triumphs, and disappointments; and I watched them persevere, blossom, and create bodies of work that they never even thought possible when they began their interest in gender-specific medicine. My collaboration with some were particularly rewarding, as evidence by my honorary memberships in the Israel, Austrian, and Korean Societies of Gender-Specific Medicine.

One of the first misapprehensions our community had to correct was that gender-specific medicine is not the study of women’s health: it is the science of how the normal physiology and experience of disease differs between males and females at all levels of existing life. It took almost a decade for our colleagues to understand that we were not politically motivated feminists with a lopsided interest in women receiving more medical attention than they had heretofore enjoyed and that in fact, we were interested in the biology that defined men as different from women in all the systems of the body. In fact, the new knowledge about female biology often caused us to reframe and/or reinterpret what we knew about men. In other words, women were making an offer men could not afford to refuse.

As I prepared to compose my own chapter, I began by printing out my curriculum vitae, which is 62 single spaced pages long—the accumulation of the work of four decades in academic medicine. Picking out the most meaningful landmarks was fun; the stories behind some of them are fascinating and worth telling about in some detail. I hope my review will be helpful to people entering this fascinating field and most of all show how life—even when it is meticulously planned—is full of unexpected twists and turns that make for a remarkable adventure.

I began life as an academically trained cardiologist, supported by the Martha Lyon Slater Fellowship and then a Senior Investigatorship from the New York Heart Association. The NIH then took over: my son was born on the day the NIH notified me that I had won a Research Career Development Award, prompting a note from my chairman remarking on the excessive nature of the double achievement. The NIH continued to support my investigative work on the ultrastructure and function of the myocardial cell. I served on NIH cardiovascular study sections and had an unparalleled opportunity to learn about the work and expertise of the leaders in my field.

These first years of my training and research were set in a period when the whole biomedical community studied only males at all levels of investigation and for economy’s sake, often used animal models, suggesting that the data told us at least something about human physiology. Looking back on this period, I referred to it as characterized by “a bikini view” of women; we assumed that only their breast and gynecologic health were unique, and that in all other respects, they were physiologically interchangeable with men. It followed, then, that all human’s experience of disease was identical. What an inexplicable (and inexcusable) intellectual error and what a long way we have come!

My own particular epiphany came in 1992 with a visit from a journalist, Carol Colman, whose mother had died of coronary artery disease (CAD). At the suggestion of the American Heart Association, she asked me to collaborate with her on a book about women’s experience of this illness; she was convinced that her mother’s risk factors, course, and outcome from CAD were not only different from that of men, but that the specific features of her illness were totally overlooked by the physicians who treated her. We wrote “The Female Heart: The Truth About Women and Coronary Artery Disease” [1], and in 1992 the American Heart Association awarded us the Blakeslee Award for the best book about heart disease for the lay public that had been published that year.

The work on the book was a paradigm shift for me, and it was the first step in my entry into gender-specific medicine. I had no idea about whether there was a difference in women’s experience of CAD and that ignorance of those differences was costing women their lives. So many things were wrong about the way we viewed women with heart disease: we believed that they were relatively immune from CAD until old age, that their distinctive symptoms were often the consequence of anxiety and other neuroses, and our treatment of them was informed by the conviction that their frailty precluded them from the kind of aggressive treatment offered to men.

In an amazing turn of events, I received an invitation to have tea with one of the men who had served as a judge for the American Heart Blakeslee award, T. George Harris, founder of Psychology Today. At that time, he was a consultant in women’s health for Procter and Gamble. He asked me if I wanted to become an advisor to the company about products created specifically for women. I replied that he had no way of knowing whether I would be a valuable consultant for a major American company, but that I had a better idea: I proposed a partnership between Procter and Gamble and Columbia University as a terrific way of opening the company’s access to expertise of all kinds.

Mr. Harris liked the idea, and I began a 2-year effort to propose the collaboration and make it a reality. I could never have done it without the support of my chairman, Dr. Myron Weisfeldt, whom I approached with the idea that (1) if women’s hearts were so different from men’s hearts, I believed other organs might be different as well and (2) that a union with a huge American corporation would be a boon for Columbia scholars. Dr. Weisfeldt’s support for these ideas never wavered—although most of the rest of the faculty thought it was a wild and doomed project and said so.

Two years of intensive work began; I used everything I could to convince P&G that we were worth an investment. Because there was nothing in the literature summarizing differences between men and women, I went to the library with my secretary (this was well before the years of Google Scholar and the internet) and we combined the library stacks at Columbia for material to produce a book, Gender-Specific Medicine for the Practicing Physician [2]. I knew I would need that to prove to P&G’s corporate chiefs and their research community that gender-specific biology was a fact and that products could be made based on our understanding of the unique needs of both sexes.

I met everyone of note in the P&G executive office during those 2 years. Two men stand out in particular: Craig Wynett, still there as a special advisor to the chairman and John Pepper, then chairman and CEO of P&G. P&G’s vetting of me was thorough: on one occasion, I addressed their 1500 researchers, most of them PhD’s, on the differences between the physiology of men and women. I remember the day my 2 years of work on the alliance were almost finished: John Pepper invited me to a private lunch in his office and opened with an unforgettable question: “Do you have the confidence of your university?” I assured him I had, although my university support at that moment consisted of Dr. Weisfeldt, period.

Finally, P&G’s top executives came to Columbia for a visit with Dean Herbert Pardes (who clearly regarded me with a great deal of skepticism). Mr. Pepper addressed the Dean with the following remark: “We have a real interest in supporting a liaison with Columbia as a result of our work with Dr. Legato, and if our discussions continue to be fruitful for another year we will support an alliance.” I rose to my feet: “Mr. Pepper, I have been in negotiations with you for two years. I have nothing more to explore, produce or offer, and if you don’t support us on the basis of what we have been able to achieve together at this point, I am giving up the idea.” The room was full of shocked silence. Fortunately, Mr. Pepper burst out laughing and a week later, Craig Wynett gave my chairman a check for a million dollars to start the Partnership for Women’s Health, later to become at my incessant urging The Partnership for Gender-Specific Medicine. One of the most telling moments in that accomplishment was Dr. Weisfeldt’s remark as I handed him the check: “Now we have to start a search for a director for the new program.” I was incredulous. I reminded him that I had worked for 2 years on the idea, developed it, achieved this improbable union with P&G, and I fully expected to be its director. He immediately agreed, fortunately, and we were off to build the program together.

A second memorable outcome of the negotiations was that I was called before two of our senior vice presidents in the course of finalizing our agreement with P&G, who questioned me about whether or not I had taken any money from P&G to work on this negotiation. The idea of taking money from P&G to achieve a partnership with Columbia had never occurred to me! To his everlasting credit, Dr. Weisfeldt, who was conducting a symposium in Florida at the time, flew back to be with me at this unexpected hearing, saying: “If they’re going to attack Legato they’ll have to attack me too!” I will never forget his defense of my integrity at that encounter (or the appalling fact that it was not necessary at all for him to have to defend me). Apparently my examiners were satisfied, but as a parting shot one of the two said to me: “Just don’t take any stock options from P&G.” Clearly, this kind of a negotiation (to engineer a union between one of America’s most powerful corporations and the medical school) was unique in their experience—as it was for me.

I tell this story in this much detail because I know that many investigators have set themselves wildly improbable goals and met with skepticism and setbacks in their attempt to achieve them. Other chapters in this book tell other stories like this one. The importance of having a mentor like Dr. Weisfeldt is an essential ingredient for success. So is the ability to think of how to exploit every opportunity for accomplishment in the byzantine world of academic medicine.

In any case, the 4-year award of 4 million dollars from P&G enabled us to produce two indexed journals and two editions of the first major textbook on the new science (Principles of Gender-Specific Medicine) in the years between 1998 and 2011. We also raised a million-dollar fund for a named professorship in Gender-Specific Medicine; we still use the income from that fund to support junior Columbia faculty: The M. Irené Ferrer Professorship in Gender-Specific Medicine, a title currently held by Dr. Elaine Y. Wan, Assistant Professor of Medicine at Columbia.

Because the chairman who followed Dr. Weisfeldt did not have any interest in the program I had begun, I resigned my full-time position at Columbia and transformed the Partnership for Gender-Specific Medicine into a private foundation, the Foundation for Gender-Specific Medicine. We have supported and continue to support scholars (two each year for the last two years at Johns Hopkins with a commitment for two more at that institution this year and six at Columbia), conduct symposia, and have produced a third edition of The Principles of Gender-Specific Medicine, with contracts from Elsevier for this book and for my next book on variations in human sexuality. With Mary Ann Liebert, Inc., publishers, I founded my third journal, Gender and the Genome, which has just been born and whose second issue is now in print.

Another important body of my work in gender-specific medicine was accomplished in a very fruitful collaboration with Dr. Vivian Pinn at the Office of Research on Women’s Health at the NIH. She was a brilliant and fascinating colleague. I served as a charter member of her advisory committee from 1995 through 1998 and had the remarkable opportunity of co-chairing a series of four nation-wide symposia about the state of women’s health. The result was our final report, Beyond Hunt Valley: Research on Women’s Health for the 21st Century. I loved that time at the NIH with Dr. Pinn: her advisory committee was a hotbed of arguments about whether biomedical scientists were consummate snobs who held the sociologic community in contempt and had no interest in separating the contribution of the environment to phenotype. What is biological sex and what is the consequence of environmental experience is still debated, but it is clear not only that both are essential components of the phenotype but operate through a final common pathway to produce the unique individual. One of my chief goals, in fact, is to find a single word that will describe the dual contribution of biological sex and the environment (“gender”). I am going to ask the IGM to think about such a word at our Japan meeting in September of this year, and will offer “gensex” as a starting suggestion.

Most of the scholars in this book list a spectacular sequence of awards and citations, including honorary PhD’s as a result of their achievements in the most recent years of their careers. I have some as well, the most significant of which to me are an honorary PhD from the University of Panama in 2015 and most recently an honorary award for Excellence in Science from the University of Messina in November of 2016.

My co-editor, Dr. Glezerman, urged me not to close my chapter without stressing the importance of cultivating and fostering the interest of laymen and women in the work we do. I have always believed that research dollars follow the interests of the public—not what scientists think is important. There was tremendous pushback at first to the idea that there was gender prejudice in health care and that women were suffering from our ignorance about the unique aspects of their basic physiology and their experience of disease. Shortly after Colman and I published our book on women’s experience of heart disease, a producer from the television show, 20/20, asked me if I were willing to appear on the show and say that women were being discriminated against by the medical establishment. He confided that no cardiologist he had approached had been willing to say that publicly but I felt we had everything to gain by highlighting the issues female patients were facing. Agreeing to appear on 20/20 was my debut in the public arena as an advocate of gender-specific research and patient care.

I have accepted every invitation to talk to the public that I was privileged to be offered: my colleagues and I worked with luminaries like Oprah Winfrey, the leaders of Hadassah, Larry King and Mehmet Oz. But small venues were just as important; people throughout the United States and the whole world found the concept of gender-specific medicine fascinating. One of the most fruitful periods of collaboration I had was in Japan with a prominent journalist, Mitsuko Shimomura, who with her own resources founded a center for women’s health in the middle of Tokyo that began the interest of that country in gender-specific medicine. My own patients have made financial and intellectual...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Foreword
• Preface
• Acknowledgments
• Chapter 1. Gender-Specific Medicine: An Idea That Should Have Been Intuitive But Which Required the Efforts of an International Community to Establish
• Chapter 2. The Making of the Israel Society for Gender Medicine (IsraGem)
• Chapter 3. A View of the History of Sex/Gender Medicine in the United States
• Chapter 4. Gender Medicine in Austria
• Chapter 5. Gender Medicine in Cardiovascular Diseases: Past, Present, and Future: Gender Medicine—What Else?
• Chapter 6. Sex and Gender in Health: The World Writes on the Body
• Chapter 7. The Charité Approach—Sex and Gender in Research, Teaching, and Policies
• Chapter 8. Gender-Specific Medicine in Italy: Point of View and Journey of Giovannella Baggio
• Chapter 9. The Future of Science Through the Lens of Gender-Specific Medicine: Rewriting the Contract
• Chapter 10. Overcoming the Skepticism to Reach Gender Equity and Appropriateness in Pharmacological Response
• Chapter 11. Gender Medicine in Italy: The Point of View of Maria Grazia Modena: The Story, Limits, and Plans: My Personal Story
• Chapter 12. Center for Gender Medicine Karolinska Institutet (KI) Since 2001
• Chapter 13. From Appalachia to West Texas: A Journey to Move Beyond One-Sex Medicine
• Chapter 14. Sex and Gender in Emergency Medicine: Advancing Care Through Person-Specific Research, Education, and Advocacy
• Chapter 15. A Comparative Physiologist’s Journey Into the Field of Sex- and Gender-Specific Medicine
• Chapter 16. A Short History of the International Society for Gender Medicine (IGM)
• Index