Skip Navigation

CHAPTER 4: DIAGNOSIS AND TREATMENT

Throughout the 20^th century, major advances in diagnosis and treatment of diseases led to dramatic reductions in women’s rates of morbidity and mortality. The first half of the century brought great strides in understanding the structure, function, and chemistry of living organisms. With ensuing decades, new drugs, chemotherapy treatments, and radiation were used to treat cancer and other diseases. Many viral and parasitic diseases that had plagued people for centuries were rarely seen, and bacterial infections were conquered through the advent of antibiotics in mid-century. Surgical techniques improved with better control of shock, the use of antibiotics, and the use of blood transfusions. Imaging technologies starting with X-ray and later including ultrasound, computed tomography scanning, positron emission tomography, and magnetic resonance imaging offered new diagnostic tools. By the end of the century, hundreds of complex machines, drugs, and procedures had been developed to diagnose and treat patients. Areas that had traditionally been the domain of women’s health also saw major advances in detection and treatment.

(Time capsule item: Alzheimer’s Disease: Unraveling the Mystery.)

Recognizing Sex and Gender-based Differences

In spite of these remarkable advances, it took the better part of the 20^th century for medical researchers, practitioners, and policy makers to directly address the issue of sex-based and gender-based differences in the diagnosis and treatment of disease. Throughout most of the century, medical research and practice were based on an andro-centric view of science. The male model was the norm. Joined to this practice were fears regarding the effects of clinical trials on women of childbearing age. The tragedies linked to the use of diethylstilbestrol and thalidomide in pregnant women in the 1950s and 1960s led to regulations in the 1970s that restricted the testing of new treatments in women of reproductive age.⁴⁶ Ultimately, this led to the widespread exclusion of women of all ages from clinical trials. Thus, women continued to use medical treatments and techniques that had been tested solely on men.

A 1990 General Accounting Office report brought to light the vast under-representation of women in federally funded clinical trials. As a result, several Federal agencies changed their policies to promote the inclusion of women in population-based studies.

In 1991 the NIH launched a landmark research effort called the Women’s Health Initiative, spearheaded by the first female director of the NIH, Dr. Bernadine Healy. This 15-year, $628,000,000 prevention study included over 65,000 women in a controlled, randomized clinical trial of diet modification, calcium and vitamin D supplements, and hormone therapy. Another component, an observational study, looked at predictors of disease in nearly 100,000 women. The initiative also included a study of community-based programs aimed at promoting healthy behaviors among women.⁴⁷

(Time capsule items: What’s So Special About Women’s Health?; NIH Office of Research on Women’s Health 10 Anniversary Program and Awards Book; Women’s Health Initiative - English and Spanish versions.)

Other research during the 1990s also revealed gender-based differences in other areas. They included health care use and costs; the probability of receiving major therapeutic procedures in acute care settings; and the likelihood of receiving major diagnostic procedures.^{48, 49} Studies also revealed gender-linked differences in patient satisfaction and communication with physicians.^{50, 51} An increasing body of evidence emerged that showed sex-based differences in disease risk, disease progression, treatment responses, and outcomes. An Institute of Medicine report concluded that “every cell has a sex” and that research should look at sex-based differences starting at the cellular level.⁵²

Sexually Transmitted Diseases

Many Americans are reluctant to discuss their sexual history with their partners, even within marriage. Consequently, both public and private awareness about the prevalence and variety of sexually transmitted diseases (STDs) remained low throughout the century.⁵³ By the 1990s, STDs accounted for 5 of the 10 most common reported infectious diseases in the United States.⁵⁴ These diseases included chlamydia, gonorrhea, AIDS, syphilis, and hepatitis B.

Human immunodeficiency virus (HIV), the deadliest of the STDs, emerged during the 1980s, predominantly among homosexual men. For years, HIV/AIDS was regarded as purely a gay men’s disease, and this view was reflected in research, public education, screening, and treatment efforts. By the end of the century, however, women represented 30 percent of new HIV infections. This increased risk to women was attributed to heterosexual contact with infected men and intravenous (IV) drug use. In the mid-1990s, evidence indicated that screening and treatment for pregnant women who were HIV-positive could greatly reduce perinatal transmission of the virus. HIV screening programs were widely implemented as part of prenatal care, but efforts to reach non-pregnant women were not as successful.

(Time capsule item: A Guide to Clinical Care of Women with HIV: 2000 Preliminary Edition.)

Mental Health

Historically, people with mental illnesses were largely cared for at home, often hidden away by relatives. In the early 19^th century, as more people began to live in crowded cities, asylums were created to house and care for the mentally ill, away from the rest of society. Reformers sought to improve the treatment of the mentally ill and protect them from abuse. Starting in the 1950s, there was a widespread movement to shift the care of the mentally ill from institutions to community-based care. This de-institutionalization movement saw its heyday in the 1980s when many mentally ill individuals were moved out of institutions. The number of state and county mental institutions dropped from a high of about 560,000 in 1955 to well below 100,000 by the 1990s. However, the community-based services that were to have been in place to take care of these individuals were often non-existent or inadequate. Many ended up homeless and without access to needed services.⁵⁵

Early in the 20^th century, mental illness in women was traditionally regarded as a form of hysteria, and not generally in the purview of medicine. Medical treatments that did exist for mental health problems often focused on removal of reproductive organs. By the late 20^th century, mental health specialists recognized that not only did women truly experience mental illnesses, but they were more at risk for major depression and anxiety disorders than were men. Nonetheless, these and other mental disorders have continually been marked by enormous social stigma.

(Time capsule items: Depression is a Treatable Disease: A Patient’s Guide; Depression Disorders in Women.)

While public understanding of what constitutes mental illness increased considerably over the course of the century, the degree of fear and stigma associated with it remained high.⁵⁶ As a result of this stigma, many people with mental illness refrained from getting help for their condition, in spite of an increasing array of effective treatments and medications. Researchers argue that the best hope for overcoming stigma and discrimination towards the mentally ill will be in the continued improvements in treatment for mental illnesses and increased public understanding of these diseases.

In spite of remarkable progress, many challenges remain for the diagnosis and treatment of disease. Women’s increased life expectancy over the century, ironically, exposed them to higher risks for chronic conditions associated with aging. New worries have evolved about the re-emergence of infectious diseases, once nearly eradicated, but now reappearing and increasingly resistant to available drugs. Concerns about access to appropriate treatments remain an unresolved issue. With the advent of telemedicine and robotics, however, comes the promise of reaching patients from greater distances, even from the comfort of their own homes. In addition, future advances in genomics, cellular biology, stem cell research, and other medical research fields may continue to increase the potential for diagnosing and treating disease.

Previous       Home       Next

Last Updated: June 2002